Costs and reimbursement of long-term ventilation

Patients receiving long-term mechanical ventilation present a serious financial challenge to hospitals. Depending on the case mix in a particular hospital of Medicare, Medicaid, managed-care contract, and fully insured patients, the financial picture in most hospitals is bleak. Depending on the level of state Medicaid reimbursement, Medicaid losses on these patients vary. Because acute care hospitals cannot be reimbursed for chronic ventilator units, hospitals have resorted to leasing space to separate entities, which, when separately incorporated, accredited, and staffed, can secure waivered status from the PPS and can be paid at a per diem rate based on their costs. Hospital patients who are ventilator dependent can be transferred to these PPS-waived units. There are states where no chronic ventilator facilities exist and where nursing homes do not accept ventilator-dependent patients. This situation is serious for the hospital if the patient does not have caregivers at home who are capable of caring for a ventilator-dependent patient. The problem of the large numbers of patients who are ventilated mechanically with endotracheal tubes but who do not fall into MDC 4 needs to be addressed by Medicare. Medicare needs to evaluate the cost and use of NIV in ICU practice and develop a system to reimburse for this modality at a reasonable level under Part A.