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Clinical, socioeconomic, and ethical dilemmas have prompted reevaluation of traditional methods of providing intensive care. Six years ago, we established a noninvasive respiratory care unit (NRCU) for selected patients in need of intensive respiratory monitoring and therapy, particularly those requiring prolonged mechanical ventilation. One impetus for the formation of the NRCU was the expectation that it might prove to be a less costly alternative to the intensive care unit (ICU) for selected patients. We reviewed data from all patients admitted to the NRCU from July 1, 1987 through June 30, 1988 to identify characteristics of the patient population and to evaluate potential cost savings. During one year of operation, 136 patients were admitted to the unit, 107 of whom were mechanically ventilated. Overall, hospital costs for these patients exceeded payments by $1,519,477. Losses were greatest for mechanically ventilated patients and those for whom Medicare or Medicaid were the primary payors. Daily costs of care for mechanically ventilated patients were $1,976 lower in the NRCU than in the medical intensive care unit (MICU). We conclude that the NRCU represents a cost-effective approach to the care of substantial numbers of patients requiring specialized respiratory care.

Mechanical ventilation is in the forefront of modern technologic advances. These advances can be life saving for some, death prolonging for others. As difficult medical, ethical, and economic issues are raised in relation to life-sustaining treatments, it is important to have as complete a data base as possible concerning costs and outcomes of mechanical ventilation, so that physicians, patients, families, and society as a whole can make appropriate decisions regarding its use.

This article provides a follow-up to an evaluation originally presented in Chest of the financial impact of diagnosis related group (DRG) payment for long-term ventilator-dependent Medicare patients at Rush-Presbyterian-St. Luke's Medical Center. Since the results of our original study were presented, the Health Care Financing Administration (HCFA) has created two new DRGs for patients who have respiratory principal diagnoses to help recognize the resource intensiveness associated with mechanical ventilator support. The original 95 patients' payment, which was originally calculated to be $2.2 million below costs, was recalculated to be $1.9 million below costs, representing a 13 percent reduction in the loss. We conclude that although HCFA's recent remedial action is a step in the right direction, it provides little relief from the DRG system's financial bias against long-term ventilator-dependent patients, because the new ventilator DRGs encompass only a small segment of these patients. As an alternative approach, we recommend a single DRG for patients who, regardless of their principal diagnoses, experience chronic respiratory failure requiring a minimum of three days of continuous ventilator treatment.

Care of ventilator-dependent patients requires considerable resources, yet the long-term outcomes of this type of care have rarely been described. We retrospectively investigated the posthospital course of elderly patients who survived an episode of prolonged ventilator dependency to describe survival rates, subsequent use of health care resources, and functional abilities. Our data suggest that the use of prolonged mechanical ventilation in the elderly produces few survivors at considerable expense. Poor overall outcomes occurred despite considerable consumption of medical and nursing resources by the survivors.

Mechanical ventilation is a life-saving medical advance. It has allowed many patients who previously would have died as a result of acute respiratory failure to survive. It has also created a population of patients who are unable to recover completely from their acute illness and who require prolonged mechanical ventilator support. The care for these patients raises many ethical, legal, social, economic, and medical issues. Data are needed to adequately meet the challenges of the ventilator-dependent patients in the future.

Much concern has been expressed about the Medicare Prospective Payment System's impact on access to care. In this study, we examine the financial impact of diagnosis-related group (DRG) payment for chronic ventilator-dependent Medicare patients. During a one-year period, payment for 95 Medicare patients who received a minimum of three days of continuous ventilator treatment and who spent no time in surgical intensive care at Rush-Presbyterian-St. Luke's Medical Center, was calculated to be $2.2 million below costs, representing an average loss per discharge of $23,129. Patients stayed an average of 26.6 days, of which 14.2 days were spent on a ventilator. We conclude that the results suggest a financial bias against chronic ventilator-dependent patients exists in the DRG system which could present access problems. We recommend three approaches to recognizing the cost of care for such patients in the DRG payment system and encourage those in public policy-making positions to use our results as the basis for a larger scale analysis of the impact of Medicare DRG payment on chronic ventilator-dependent patients.