ICU Access and Prospective Payment

To the Editor. —  In the article entitled "The Early Effect of Medicare's Prospective Payment System on the Use of Medical Intensive Care Services in Three Community Hospitals,"1 the authors conclude "that within an increasingly cost-conscious hospital environment, ICU [intensive care unit] bed availability decreased and physicians discharged MICU [medical intensive care unit] patients earlier without affecting in-hospital or six-month mortality or severity of illness in the MICU." These conclusions deserve scrutiny. The Prospective Payment System serves basically as a form of implicit rationing imposed on hospitals and physicians. What the current study and other studies the authors cite show is that when ICU beds are rationed within certain limits, physicians can adjust their admitting patterns with no attendant increase in the mortality of ICU patients. This is not the same as demonstrating no detrimental effects when ICU beds are rationed, since those most affected by rationing are the patients