Academic journal article Health Care Financing Review

Inpatient Transfer Episodes among Aged Medicare Beneficiaries

Academic journal article Health Care Financing Review

Inpatient Transfer Episodes among Aged Medicare Beneficiaries

Article excerpt


Transfers of Medicare beneficiaries from one hospital to another have received limited study. Although there have been studies of the cost implications of transfers for hospitals (Jencks and Bobula, 1988), little is known, at the patient level, about the types of medical conditions associated with transfers of aged Medicare beneficiaries either when first admitted or after transfer. This article examines discharge data for 152,337 hospitalized Medicare aged beneficiaries (65 years of age or over) who were transferred from one acute care facility to another during fiscal year (FY) 1987, to determine the conditions (diagnosis-related groups [DRGs]) most associated with transfers, the complexity of these conditions (DRG weight, incidences of surgery, number of payment outlier cases [under Medicare's prospective payment system (PPS)]) and differences in conditions, incidences of surgery and charges between initial and final stays in a transfer hospitalization episode and transfer stays and stays for all Medicare aged beneficiaries. The types of hospitals participating in transfers (e.g. teaching hospitals, disproportionate share hospitals [DSHs], rural referral centers [RRCs], and sole community hospitals [SCHs]) are examined.(1) The implications of the data presented for development of networks of inpatient facilities and for costs of care and reimbursement are also discussed.


The transfer of a patient from one hospital to another has historically occurred in instances where a patient requires treatment that is either unavailable at the hospital initially admitting the patient or could be performed more efficiently with better outcomes in another hospital. Often the required treatment is complex and technology-intensive, such as coronary bypass operations or organ transplants, and is in many instances referred to as "tertiary care." Sending admitted patients to hospitals specializing in tertiary care when such care is needed can be viewed as beneficial to quality of care and a justification for "regionalization" of such activity in hospitals specializing in tertiary care (Hughes, Hunt, and Luft, 1987; Maerki, Luft, and Hunt, 1986). Hospitals specializing in these types of complex modes of treatment are usually teaching hospitals.

Discharge-level research by the staff of the Prospective Payment Assessment Commission (ProPAC) found that the rate of transfers (transfers per 10,000 live discharges) had increased by about 25 percent from 1984 to 1988 and that the annual rate of increase in transfers was about 9 percent (Prospective Payment Assessment Commission, 1990a). Transfer rates declined with age and were substantially lower for beneficiaries 80 years of age or over than for beneficiaries under 80 years of age. This is expected because older beneficiaries are generally less likely to receive surgery or major operating room (OR) procedures because of their higher likelihood of comorbidities. However, many elderly Medicare beneficiaries live in rural areas, where patients needing major surgical procedures are often referred to urban hospitals or RRCs.

Sloan, Morrisey, and Valvona (1988), using Commission on Professional and Hospital Activities (CPHA) data containing discharges from a sample of 467 hospitals for 4 years (1980, 1983, 1984, and 1985), found an increase in transfer rates from 1983 to 1985, but found far less evidence of a trend toward increased transfer rates when data for 1980 were also considered, suggesting that the increase in transfers following PPS may be caused by other factors in addition to the beginning of PPS. Among Medicare patients, transferred cases were in no instance more than 3 percent of total Medicare discharges. Sloan et al. (1988) also found that most of the conditions representing a high volume of transfers involved some type of cardiovascular condition.


Much of the initial research on cost implications of transfers occurred as part of research directed toward determining why teaching hospitals have higher costs than non-teaching hospitals, as Pettengill and Vertrees (1982), Cameron (1985), and Sloan, Feldman, and Steinwald (1983) suggested. …

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