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The emperor has no clothes: a misguided case for long-term acute-care facilities?

The recent development of long-term acute-care facilities in the United States seems at first to be a reasonable evolution of centers developed to manage the weaning of chronically ventilator-dependent patients. However, on closer reflection, the designation "long-term acute care" appears to be an oxymoron because a synonym would be "chronic acute care." Specialized weaning centers have demonstrated some success with weaning patients from chronic ventilation but depend on highly selective admission criteria (1). As yet, there is no randomized trial actually demonstrating that these centers achieve greater success than conventional intensive care units. Apparently, one reason leading to the growth of these centers is the reimbursement system in the United States. Although acutecare facilities are reimbursed a fixed amount based on each patient's diagnosis-related group, chronic-care facilities are reimbursed based on actual cost. In this issue of Critical Care Medicine, Dr. Seneff and colleagues (2) examine the outcome and cost of care for patients transferred to a chronic acute-care facility. The authors conclude that outcomes are not different for patients treated at an acute-care facility compared with those transferred to chronic acute care, but the acute-care hospitals can reduce the amount of uncompensated care by earlier transfer. The argument for cost savings made in this study illustrates fundamental flaws in this approach to funding.