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COGNITIVE AND FUNCTIONAL STATUS OF THE JAPANESE OLDEST OLD

In reply: Dr. von Sternberg’s comments about our paper are apt. As we tried to indicate, we saw this report as simply a trail-blazing exercise into the new country of subacute care. For some, subacute care represents a rediscovery of an earlier component of hospital care, called progressive patient care, where patients are treated with declining intensity according to their condition. Subacute care likes to describe itself as filling a gap between the hospital and the nursing home. In fact, subacute care must also compete with home health care. It is not a coincidence that Dr. von Sternberg’s proposed outcome measures come from rehabilitation and home health. More work is sorely needed to classify subacute care and to assess its outcomes. Andrew Kramer and his colleagues are concluding a substantial study that should add valuable information in this regard. Subacute care has become big business. Corporations devoted to this work are traded on Wall Street. Three basic questions must be addressed: (1) What is it? (2) Does it work? and (3) What is it worth? We were limited to using structural characteristics, but one would hope to see more about the actual process of care in subsequent studies. The outcomes work will need to measure change in meaningful units and at the right times. If discharge from hospital is the launching point, follow up must extend beyond discharge from subacute care. The outcomes will have to include functional measures as well as subsequent utilization. The comparison groups should include both those treated in nursing homes and those treated at home. However, if patients are discharged from hospitals earlier because they can enter subacute care, hospital discharge is not an even starting point. At the very least, some form of extensive case-mix adjustment will be needed to produce fair comparisons with effectiveness. Its value depends on one’s perspective. For Medicare, subacute care is an added expense. Hospitals continue to be paid on the basis of a presumed hospital stay. Unless funds can be transferred from hospital payments, Medicare winds up paying twice. A more expensive rate for nursing homes that provide so-called subacute care is no bargain for Medicare. One possibility would be bundling the costs of hospital and post-hospital care into a single payment. Then hospitals might be interested in buying subacute care if it could save them hospital days and still achieve the same outcomes. At present, some managed care plans that do not pay hospitals on the basis of DRGs see subacute care as a good buy if it reduces expensive hospital stays. We hope our study will be viewed as the beginning of a series of work that needs to address carefully the emerging concept of subacute care. Medical care has witnessed numerous technological innovations that were assessed adequately only after they were well installed as standard modes of care. At best, we will be able to get a jump on this innovation despite the enormous economic implications it holds. Perhaps one benefit from the new comodification of health care is a greater willingness to wait for better information before rushing to purchase the latest fad.