Hostname: page-component-78c5997874-v9fdk Total loading time: 0 Render date: 2024-11-10T15:04:52.843Z Has data issue: false hasContentIssue false
  • English
  • Français

Legal and Ethical Implications of Health Care Reimbursement by Diagnosis Related Groups

Published online by Cambridge University Press:  28 April 2021

Marshall B. Kapp
Get access Rights & Permissions [Opens in a new window]

Extract

The major challenge facing the American health care system today is to devise a strategy for achieving three primary objectives simultaneously: (1) high quality, or excellence in standards of care, (2) balance, or equitable access to that quality care, and (3) some reasonable semblance of cost control in providing that quality care to everyone. Following World War II, the weight of government was thrown solidly behind the access and quality portions of the equation, first with the enactment of the Hill-Burton capital financing program and its accompanying community service obligations, and accelerating in the midsixties through creation of Medicare, Medicaid, and other financing and delivery programs entitling categories of individuals to health care benefits.

Type
Article
Information
Law, Medicine and Healthcare , Volume 12 , Issue 6 , December 1984 , pp. 245 - 278
Copyright
© 1984 American Society of Law, Medicine & Ethics

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Hill-Burton Act, 42 U.S.C. §291 (a–b) (1982).Google Scholar
42 U.S.C. §§ 1395 (Medicaid), 1396 (Medicare) (1982).Google Scholar
Prospects for Medicare's Hospital Insurance Trust Fund, S. Rep. No. 98-17, 98th Cong., 1st Sess. (March 1983); The Future of Medicare: Hearings Before the Senate Special Committee on Aging, 98th Cong., 1st Sess. (April 1983); Iglehart, J. K., Medicare's Uncertain Future, New England Journal of Medicine 306(21): 1308–12 (May 27, 1982).Google ScholarPubMed
Physicians Still See Costs as Medicine's No. 1 Problem: Poll, American Medical News, January 13, 1984, at 2.Google Scholar
The Equitable Healthcare Survey: Options for Controlling Costs (Louis Harris & Associates, Inc., New York, N.Y.) (1983).Google Scholar
Saward, E.W. Gallagher, E.K., Reflections on Change in Medical Practice, Journal of the American Medical Association 250(20): 2820–25 (November 25, 1983).Google ScholarPubMed
Iglehart, J.K., Medicare Begins Prospective Payment of Hospitals, New England Journal of Medicine 308(23): 1428–32 (June 9, 1983).Google ScholarPubMed
Derzon, R.A., Medicare, the Aged and the Disabled, Bulletin of the New York Academy of Medicine 60(1): 66–78 (January/February 1984).Google ScholarPubMed
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Securing Access to Health Care: The Ethical Implications of Differences in the Availability of Health Services (U.S. Gov't Printing Ofc., Washington, D.C.) (Vol. 1, 1982) at 23 [hereinafter referred to as Securing Access to Health Care]; Lubitz, J. Prihoda, R., The Use and Costs of Medicare Services in the Last Two Years of Life, Health Care Financing Review 5(3): 5 (Spring 1984).Google Scholar
1981 White House Conference on Aging, Chartbook on Aging in America (U.S. Gov't Printing Ofc., Washington, D.C.) (1981) at 82–87. See also Bayer, R., Will the First Medicare Generation Be the Last? Hastings Center Report 14(3): 14 (June 1984).Google Scholar
Brown, L.D., The Prospects for Prospective Payment, Journal of Health Politics, Policy and the Law 7(4): 987–99 (Winter 1983).Google Scholar
42 U.S.C. §1320B-5(c) (1982).Google Scholar
97 Stat. 65 (April 1983).Google Scholar
48 Fed. Reg. 39,752 (September 1, 1983) (to be codified at 42 C.F.R. §§ 405, 409, 489).Google Scholar
49 Fed. Reg. 234 (January 13, 1984) (to be codified at 42 C.F.R. §§ 405, 489).Google Scholar
Senate Special Committee on Aging, Current Developments in Prospective Reimbursement Systems for Financing Hospital Care, An Information Paper (U.S. Gov't Printing Office, Washington, D.C.) (1983).Google Scholar
Many States Seeking to Cut Medicaid Costs, New York Times, October 14, 1984, at 1 (Nevada, New Jersey, Ohio, Pennsylvania, Utah, and Washington have set up such programs).Google Scholar
The Revised DRGs: Their Importance in Medicare Payments to Hospitals (Ernst & Whinney Co., Cleveland, Oh.) (1983).Google Scholar
General Accounting Office, U.S. Congress, Need to Eliminate Payments for Unnecessary Hospital Ancillary Services (U.S. Gov't Printing Ofc., Washington, D.C.) (1983).Google Scholar
Iglehart, J.K., The New Era of Prospective Payment for Hospitals, New England Journal of Medicine 307(20): 1288–92 (November 11, 1982).Google ScholarPubMed
Enthoven, A.C., Shattuck Lecture—Cutting Cost without Cutting the Quality of Care, New England Journal of Medicine 298(22): 1229–38 (June 1, 1978).Google ScholarPubMed
Holsinger, J.W., Cost Versus Quality, in Hospital Quality Assurance: Risk Management and Program Evaluation (Pena, J.J. Haffner, A.N. Rosen, B. Light, D.W., eds.) (Aspen Systems, Rockville, Md.) (1984) at 89–103.Google Scholar
Coping with Prospective Payment for Health Care: Loopholes, Anxiety, and Sudden Change, Hospital and Community Psychiatry 35(3): 291–92 (March 1984).Google Scholar
49 Fed. Reg. 304-05 (January 3, 1984) (to be codified at 42 C.F.R. §§ 405, 409, 489).Google Scholar
49 Fed. Reg. 307-08 (January 3, 1984) (to be codified at 42 C.F.R. §§ 405, 409, 489).Google Scholar
49 Fed. Reg. 282-88 (January 3, 1984) (to be codified at 42 C.F.R. §§ 405, 409, 489). See Mihalski, E.J., The New Era of Utilization and Quality Control: Professional Review Organizations, Bulletin of the New York Academy of Medicine 60(1): 48–53 (January/February 1984).Google ScholarPubMed
49 Fed. Reg. 318 (January 3, 1984) (to be codified at 42 C.F.R. §§ 405, 409, 489).Google Scholar
49 Fed. Reg. 309 (January 3, 1984).Google Scholar
Silver, G.A., Solution by Acronym, Lancet 2(8364): 1433–34 (December 1983); Johnson R.L., Shooting Oneself in the Foot: Congress May Re-Create Two-Tier Care, Hospital Progress 64(12): 32–39 (December 1983); Leaf L., The Doctor's Dilemma—and Society's Too, New England Journal of Medicine 310(11): 718–21 (March 15, 1984).Google ScholarPubMed
Iglehart, J.K., Medicare's Uncertain Future, New England Journal of Medicine 306(21): 1308–12 (May 27, 1982).Google ScholarPubMed
NJ Hospital Protects Against Early Discharge, Hospitals 57(24): 57 (December 16, 1983), quoting Milch, Ronald B., Executive Director, Beth Israel Hospital, Passaic, N.J.Google Scholar
Iglehart, J.K., New Jersey's Experiment with DRG-Based Hospital Reimbursement, New England Journal of Medicine 307(26): 307, 1660 (December 23, 1982).Google ScholarPubMed
Bollet, A.J., A New Era in Medicine, Resident and Staff Physician 30(3): 21–22 (March 1984).Google ScholarPubMed
Bergen, S.S. Jr. Roth, A.C., Prospective Payment and the University Hospital, New England Journal of Medicine 310(5): 316–18 (February 2, 1984).Google ScholarPubMed
See, e.g., Johnson, , supra note 29.Google Scholar
Havighurst, C.C. Blumstein, J.F., Coping with Quality/Cost Trade-offs in Medical Care: The Role of PSROs, Northwestern University Law Review 70(1): 6–68 (March/April 1975); Blumstein J.F., Rationing Medical Resources: A Constitutional, Legal, and Policy Analysis, Texas Law Review 59(8): 1345–1400 (November 1981).Google Scholar
Securing Access to Health Care, supra note 9, at 13.Google Scholar
Dooley, M.R. Johnson, J.A., Trends in the Industry: Adjusting to Change, Florida Bar Journal 58(3): 139–41 (March 1984).Google Scholar
Cranford, R.E. Doudera, A.E., The Emergence of Institutional Ethics Committees, Law, Medicine & Health Care 12(1): 13–20 (February 1984).Google ScholarPubMed
McPhee, S.J., Cost Containment Confronts Physicians, Annals of Internal Medicine 100: 604–06 (1984).Google ScholarPubMed
Schwartz, W.B. Komesar, N.K., Doctors, Damages, and Deterrence: An Economic View of Medical Malpractice, New England Journal of Medicine 198(23): 1282–89 (June 8, 1978).Google Scholar
Symposium: The Potential Impact of Diagnosis-Related Groups on Long-Term Care, Pride Institute Journal of Long Term Home Health Care 2(4): 3–9 (Fall 1983).Google Scholar
Kleyman, P., Medicine's Prospective Pricing System: An Introduction to DRGs, Their Complications and Co-Morbidities, Coordinator 3(1): 23–24, 29 (February 1984).Google Scholar
Nemore, P., Medicare Prospective Payment for Hospitals: Implications for Nursing Home Residents, Clearinghouse Review 17(12): 1308–12 (April 1984).Google Scholar
Wennberg, J. McPherson, K. Caper, P., Will Payment Based on Diagnosis-Related Groups Control Hospital Costs? New England Journal of Medicine 311(5): 311 (August 2, 1984). See Wasserman J., Case Study: The Doctor, the Patient, and the DRG, Hastings Center Report 13(5): 23–25 (October 1983).Google ScholarPubMed
Milan, K., Will DRG Payments Creep into All United States Health Insurance Plans, Canada Medical Association Journal 130: 912–15 (April 1, 1984).Google Scholar
See, e.g., advertisement, in Hospitals 58(2): 58 (January 16, 1984).Google Scholar
Curran, W.J. Moseley, G.B., The Malpractice Experience of Health Care Maintenance Organizations, Northwestern University Law Review 70(1): 69–89 (March/April 1975).Google Scholar
Nathanson, P., Future Trends in Aging and the Law, Generations 8(3): 7–9 (Spring 1984); Rosenblatt R.E., Rationing “Normal” Health Care: The Hidden Legal Issues, Texas Law Review 59(8): 1401–20 (November 1981).Google Scholar
Cunningham, R.M. Jr., Entrepreneurialism in Medicine, New England Journal of Medicine 309(21): 309, 1313 (November 24, 1983).Google ScholarPubMed
Brahams, D., End-Stage Renal Failure: The Doctor's Duty and the Patient's Right, Lancet 1(8373): 386–88 (February 18, 1984).Google ScholarPubMed
See generally Fiscina, S., Medical Law for the Attending Physician (Southern Illinois University Press, Carbondale, Ill.) (1982).Google Scholar
Schuck, P.H., Malpractice Liability and the Rationing of Care, Texas Law Review 59(8): 1421–27 (November 1981).Google ScholarPubMed
42 U.S.C. §§ 1320c-1 to 19 (Supp. II, 1972). See Smits, H.L., The PSRO in Perspective, New England Journal of Medicine 305(5): 253–59 (July 30, 1981); Goran M.J., The Evolution of the PSRO Hospital Review System, Medical Care 17(5): 1–47 (May 1979 supp.).Google Scholar
Havighurst, C.C., Deregulating the Health Care Industry (Ballinger Publishing Co., Cambridge, Mass.) (1982) at 26, 31.Google Scholar
Aaron, H.J. Schwartz, W.B., The Painful Prescription (Brookings Institution, Washington, D.C.) (1984); Schwartz W. B. Aaron H. J., Rationing Hospital Care: Lessons from Britain, New England Journal of Medicine 310(1): 52–56 (January 5, 1984); Stevens R., Comparisons in Health Care: Britain as Contrasted to the United States, in Handbook of Health, Health Care, and the Health Professions (Mechanic D., ed.) (Free Press, New York, N.Y.) (1983) at 281–304.Google Scholar
Smits, H.L., The Clinical Context of Technology Assessment, Journal of Health Politics, Policy and the Law 9(1): 31–40 (Spring 1984).Google ScholarPubMed
Painful Prescription, supra note 56, at 131–33.Google Scholar
Grimaldi, P.L. Micheletti, J.A., Diagnosis Related Groups: A Practitioner's Guide (Pluribus Press, Chicago, Ill.) (1983) at 155.Google Scholar
S. Rep. 23, 98th Cong. (1983).Google Scholar
Ginsburg, P.A. Sloan, F.A., Hospital Cost Shifting, New England Journal of Medicine 310(4): 893–98 (April 5, 1984).Google ScholarPubMed
Trends Suggest More Legal Disputes Ahead for Hospitals, Hospitals 58(3): 35–36 (February 1, 1984).Google Scholar
Bayer, R., The Care of the Terminally Ill: Morality and Economics, New England Journal of Medicine 309(24): 1490–94 (December 15, 1983).Google ScholarPubMed
Bernstein, A.H., Medical Staff Privilege Disputes, Hospitals 58(8): 85–88 (April 16, 1984).Google ScholarPubMed
Bollet, A.J., A New Era in Medicine, Medical Times 111(12): 13–17 (December 1983).Google Scholar
Grimaldi, P.L., Final Prospective Payment Rules Contain Critical Revisions, Hospital Progress 65(3): 42–43, 60 (March 1984).Google Scholar
Light, D.W., Is Competition Bad? New England Journal of Medicine 309(21): 1315–19 (November 24, 1983).Google ScholarPubMed
Katz, J., Why Doctors Don't Disclose Uncertainty, Hastings Center Report 14(1): 35–44 (February 1984).Google ScholarPubMed
Rubenstein, H.S., Standards of Medical Care Based on Consensus Rather Than Evidence: The Case of Routine Bedrail Use for the Elderly, Law, Medicine & Health Care 11(6): 271–76 (December 1983).Google ScholarPubMed
Ball, J.R., Prospective Payment: Implications for Medical Technology, Annals of Internal Medicine 100: 606–07 (1984).Google ScholarPubMed
Jirka, F.J. Jr., Editorial: Three Major Challenges: Quality, Cost, and Balance, Journal of the American Medical Association 251(14): 1867–68 (April 13, 1984).Google ScholarPubMed
Rosen, H.M. Sussman, E.J., Making Peer Review More Productive, Journal of the American Medical Association 250(17): 2305–06 (November 4, 1983).Google ScholarPubMed
Office of Technology Assessment, U.S. Congress, Diagnosis Related Groups and the Medicare Program: Implications for Medical Technology (U.S. Gov't Printing Ofc., Washington, D.C.) (1983).Google Scholar
Ball, supra note 70, at 606–07.Google Scholar