The inclusion criteria yielded 27,733,310 beneficiaries aged 65 years and older in 1992 and 28,510,520 in 2002. summarizes elderly inpatient stays with a primary NDPI diagnosis by facility type and ownership. The number of these stays fell from 193,962 in 1992 to 183,505 in 2002, which corresponds to a decline from 699 stays per 100,000 eligible Medicare beneficiaries 65 years or older in 1992 to 644 stays per 100,000 in 2002. The number of different facilities having at least one inpatient stay from an eligible beneficiary rose from 10,684 in 1992 to 13,112 in 2002, due to an increase in number of SNF facilities from 3,931 in 1992 to 6,896 in 2002.
Volume, duration and costs of non-dementia psychiatric illness (NDPI) inpatient stays of elderly medicare beneficiaries in 1992 and 2002 by facility ownership and typea
During the same period, the total number of elderly NDPI stays in SNFs rose from 8,542 to 17,312 (mostly due to increased use of for profit owned SNFs). This corresponds to an average of only ~2 stays per SNF facility during these years. Large portions of all inpatient NDPI stays were in psychiatric units of general hospitals; 41.7% (on average 62.7 stays per facility having at least one stay) in 1992 rising to 51.7% (on average 67.3 stays per facility having at least one stay) in 2002. From 1992 to 2002, the portion of all elderly NDPI stays in general hospital beds declined from 34.5% to 27.4% and in long-stay units declined from 19.5 to 11.3% (mostly due to decreased use of for profit owned long-stay hospitals), while the mean number of stays (per facility having at least one stay) for long-stay hospitals declined from 51.5 to 21.6.
Looking at all elderly NDPI stays combined, from 1992 to 2002, mean (±standard error of mean) Medicare charges per stay (in 2002 dollars) declined from $8,461 (±$31) to $6,207 (±$21) () and mean charges to beneficiaries declined from $955 (± $4.5) to $692 (±$3.2) (data not shown). During this same time period, for all stays collectively, mean numbers of Medicare covered days per stay declined from 14.9 (±0.03) to 12.1(±0.03). In general, comparable declines in mean Medicare expenditures, covered days and beneficiary expenditures occurred from 1992 to 2002 in long-stay hospitals, psychiatric units and general hospital beds. But for SNFs, from 1992 to 2002, mean Medicare covered days remained stable around 26 per stay while mean Medicare covered costs rose from $4,153 to $6,375.
In 2002 Medicare covered on average the least mean days per elderly NDPI stay (5.5 days) for general hospitals and comparable mean days per stay for long-stay hospitals (14.1) and psychiatric units (12.5). Similarly, in 2002 mean Medicare expenditures for general hospital bed stays ($3,770) were about half the mean Medicare expenditures for long-stay hospitals ($6,482) and psychiatric units ($7,462). In 1992 and 2002, elderly beneficiaries in SNFs were charged on average $1,916 and $1,490 per NDPI stay, respectively, while other facilities charged these elderly on average $788–$1,017 in 1992 and $565–$797 in 2002 (data not shown).
There were some relatively minor changes in the distribution of primary diagnoses associated with elderly NDPI stays from 1992 to 2002 (). Major depression dropped from 40.4% of all such stays in 1992 to 37.4% in 2002, while substance abuse dropped from 14.5 to 13.4%, bipolar illness rose from 9.2% to 10.9%, schizophrenia rose from 8.2 to 10.6%, and “other conditions” held constant at 27.7% during this period. The biggest disparity in the distribution of NDPI diagnoses by facility type was seen between SNFs and other facilities: for 65% of SNF stays in 1992 and for 48% in 2002, the primary diagnosis was of “other NDPI condition” whereas only ~26% of primary diagnoses fell in this category for stays at all other facilities combined during these years (data not shown). In general, in 1992 and 2002, stays for primary diagnoses of schizophrenia, bipolar disorder and depression were associated with higher Medicare charges and more covered days than were stays for substance abuse and “other” diagnoses. But mean Medicare costs and covered days per stay declined for all diagnoses from 1992 to 2002. In 2002, schizophrenia stays were associated with the greatest mean Medicare charges and days ($7,793 and 16.2 days, respectively), and substance abuse stays with the least ($3,786 and 6.7 days, respectively).
Volume, duration and costs of non-dementia psychiatric illness (NDPI) inpatient stays of elderly medicare beneficiaries in 1992 and 2002 by primary diagnosisa
We further analyzed 1992 and 2002 reimbursement of elderly NDPI inpatient stays by both primary diagnosis and facility type (data not shown). In general, for each NDPI primary diagnosis stay, Medicare covered the most number of days in SNFs (mean always > 20 days) and the least days (mean usually < 10) in general hospital scatter beds. Between 1992 and 2002, for all primary NDPI diagnoses at SNFs, mean Medicare covered costs per stay increased, while mean beneficiary charges decreased and mean Medicare covered days remained relatively stable. During this same time period, for elderly stays at long-stay hospitals, acute psychiatric units and general hospital beds; mean Medicare costs, Medicare covered days and beneficiary charges per stay tended to decline for all NDPI primary diagnoses.
describes characteristics of elderly NDPI stays by gender, race, age group and non-NDPI secondary diagnoses. From 1992 to 2002, the portion of elderly NDPI stays from patients aged 65 to 74 declined from 54.1 to 46.8% while those from patients 85 or older rose from 10.6% to 14.9%. In both 1992 and 2002, NDPI stays in SNFs as compared to stays in other institutions tended to involve relatively older patients. Nevertheless, SNF stays in 2002 were by patients who tended to be somewhat younger than the NDPI patients seen in SNFs in 1992. From 1992 to 2002, the portion of SNF stays with a primary NDPI diagnosis involving patients aged 65–74 increased from 22.8 to 26.5%, and the portion involving patients aged 85+ declined from 32.1 to 29.6%.
Volume, duration and costs of non-dementia psychiatric illness (NDPI) inpatient stays of elderly medicare beneficiaries in 1992 and 2002 by facility ownership and patient characteristicsa
Overall, the portion of elderly NDPI stays from White patients declined from ~89% in 1992 to ~87% in 2002 as the portion from Black patients rose from ~7 to ~9%, with similar changes seen across all facility types. Qualitatively, both overall and within facilities, Medicare covered days and charges per stay did not differ dramatically or consistently by racial group. Overall, in both 1992 and 2002, (a) about 65% of the elderly inpatient NPDI stays were by women and stays by women entailed on average about 2 more covered Medicare days and $1,000 more Medicare expenditures than did stays by men, and (b) psychiatric units, which overall had the highest mean costs and duration per stay, had the greatest gender disparity with close to 70% of stays being by women, while general hospital scatter beds, which overall had low mean costs and duration per stay, had the least gender disparity with 58.5% of stays being by women.
From 1992 to 2002, the portion of NDPI stays with non-NDPI secondary diagnoses noted rose from 45.8 to 66.3%. While SNFs had high proportions of stays for which secondary illnesses were reported (75% or more) in both 1992 and 2002, the proportion of such stays increased to a similar level in 2002 in both general hospital scatter beds and general hospital psychiatric units. Overall (all facility types combined), elderly NDPI stays with secondary diagnoses were not linked to greater Medicare expenditures at either time point, and in fact had fewer Medicare covered days than did those without secondary conditions. When comparing stays within each facility type, there were no consistent or dramatic associations linking stays with secondary diagnoses to differential amounts of Medicare expenditures or of covered days. Despite the high rate at which they tended to have secondary diagnoses noted, stays in general hospital beds and SNFs had lower Medicare expenditures and involved fewer covered days than did stays in the other two, more psychiatrically specialized facility types.