The Cost of Critical Care Background

Intensive care costs more than $200 billion in the United States, up to 1.5% of GDP. In Great Britain, intensive care beds cost 3 to 5 times that of standard ward beds. Indeed intensive care beds constitute only 5-10% of most hospitals’ bed numbers, yet consume over 30% of hospital budgets.  A number of issues regarding intensive care need to be kept in mind:

The number of intensive care beds is growing universally, yet there is little quantitative evidence that intensive care provides an irrefutable benefit. There is no predetermined standard for intensive care in terms of case mix and quality of care. Indeed there is a huge difference in transatlantic practices in intensive care with regard to admission and discharge criteria [Chalfin 1995].  Society believes intensive care to be beneficial. Nevertheless, many patients are admitted to ICU who would have done as well (at considerably less cost) in an intermediate (high dependency) care unit. Many patients are admitted to ICU when death is inevitable. Resources are diminishing, and budgetary constraints has led to society asking the question “is it worth it?”

There is no doubt that baseline costs in ICU are very high. This is inevitable, and accepted. What really challenges healthcare managers is the constant introduction of new technologies that may affect the hospital’s budget. Three points of view should be taken into account: 1. The relatives/patient, who want treatment irrespective of cost. 2. The clinician who wishes to use the most effective treatment. 3. The economist who seeks to minimise costs. In the case of the first group, the issue is subjective. The empowerment of “next of kins” is considered to be in the best interest of the patient; this is arguable. Controversy is well documented in neonatal intensive cares, where the continued resuscitation of marginally viable neonates has led to some concern (Silverman 1997).

The combination of the views of the clinician and the economist, that of cost minimisation by utilising economic-clinical evaluations, has no power in an environment where society dictates that “all that can be done should be done”. This is the critical rate limiting step in all medical economic evaluations. The strategy that clinical managers must follow is cost effectiveness in an ethical environment. One cannot separate ethics from management in intensive care.

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