Get ready for some more CYA medicine!

[Taurus]

---

Members don't see this ad.

http://www.nytimes.com/2007/08/19/washington/19hospital.html?_r=1&hp&oref=slogin

Medicare Says It Won’t Cover Hospital Errors

By ROBERT PEAR
Published: August 19, 2007

WASHINGTON, Aug. 18 — In a significant policy change, Bush administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars.

Private insurers are considering similar changes, which they said could multiply the savings and benefits for patients.

Under the new rules, to be published next week, Medicare will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.”

Among the conditions that will be affected are bedsores, or pressure ulcers; injuries caused by falls; and infections resulting from the prolonged use of catheters in blood vessels or the bladder.

In addition, Medicare says it will not pay for the treatment of “serious preventable events” like leaving a sponge or other object in a patient during surgery and providing a patient with incompatible blood or blood products.

“If a patient goes into the hospital with pneumonia, we don’t want them to leave with a broken arm,” said Herb B. Kuhn, acting deputy administrator of the Centers for Medicare and Medicaid Services.

The new policy — one of several federal initiatives to improve care purchased by Medicare, at a cost of more than $400 billion a year — is sending ripples through the health industry.

It also raises the possibility of changes in medical practice as doctors hew more closely to clinical guidelines and hospitals perform more tests to assess the condition of patients at the time of admission.

Hospital executives worry that they will have to absorb the costs of these extra tests because Medicare generally pays a flat amount for each case.

 

[Law2Doc]

Hospital executives worry that they will have to absorb the costs of these extra tests because Medicare generally pays a flat amount for each case.

I don't know about that (more CYA) -- this last sentence suggests to me that a lot of hospitals are going to run for luck. It will be a balancing test of how few tests they can manage to order and not incur more backend expense. You'll probably see a whole lot more patients tied down or sedated to not fall though. Won't make the hospital as pleasant a place for some.

 

[RxnMan]

I could see it go both ways. Hospitals could go for NASA-style zero error with massive workups, if Medicare/Medicaid would fund it. Or hospitals could say hey, we get x dollars whether the patient do well or not, so let's balance risk of complications vs. cost of workups.

The tipping point is liability and malpractice. It's still too easy to file suit on a poor outcome and tie up a doc in court, even on a frivolous case. This would increase if workups were reasonably reduced/reallocated via the flat reimbursement. Otherwise I would agree with Law2Doc.

 

[Taurus]

From now on, every patient who gets admitted will get blood, urine, and stool cultures as part of any workup. 🙂

 

[Law2Doc]

The tipping point is liability and malpractice. It's still too easy to file suit on a poor outcome and tie up a doc in court, even on a frivolous case.

I suspect this won't really change depending on whether it's funded or not. If the test was one you should have ordered, it is something you can get sued on for not doing so, regardless of who is paying the bills. But the flip side is the more you order, the more things you are at fault for not looking at or misinterpreting. So it's often a wash.

 

[carrigallen]

The key term is "reasonably prevented". You can reduce the risk of many hospital-acquired complications, but there aren't as many which can be completely prevented.
Most guidelines are designed to reduce the relative risk of a complication, not prevent it from occuring. That is a key distinction.

For example:

• SQ heparin reduces the relative risk of a DVT by 2-3 fold, but it does not completely prevent the formation of a DVT.
• Peri-operative antibiotics reduce the relative risk of surgical wound infections, but they cannot prevent 100% of wound infections from occuring.
• Blood typing and matching reduces the risk of a transfusion-associated reaction, but cannot prevent all reactions from occuring.

The same can be said for prophylactic measures against C.Diff colitis and line-associated bacteremia. If you have an unstable patient with a CD4 of 10, they can get a line infection from a line that is in for only a few days. No way to prevent that. C.Diff organisms are everywhere, and there is no way to eradicate them from the patient's own bowel flora.

 

[Tired]

I can't believe this proposal is controversial.

 

[Sol Rosenberg]

In addition, Medicare says it will not pay for the treatment of “serious preventable events” like leaving a sponge or other object in a patient during surgery and providing a patient with incompatible blood or blood products.

Hel-lo, why should it? Does Medicare currently pay for the treatment/correction of doctor's/staff screw-ups aka "serious preventable events" as described above? Those should be on the doctors/hospital.

 

[dilated]

Hel-lo, why should it? Does Medicare currently pay for the treatment/correction of doctor's/staff screw-ups aka "serious preventable events" as described above? Those should be on the doctors/hospital.

Hel-lo, have you considered the possibility that this is just going to be another example of cost shifting? Using the example of DVTs, you could order a 400 dollar u/s on every high risk patient and spend 40000 dollars finding a DVT. Congratulations, the system just paid 40 grand+ so the hospital doesn't have to pay for that DVT themselves. By giving the hospital such a ridiculously high incentive to avoid these few things you're creating even more inefficiency. Let's hear it for CMS!

 

[RockShox]

This is a totally stupid idea. Technique #1 of popular government: The general public can be made to support most things if you partually couch it in a common good issue and then make all other terms ambigious all the while stating a course action that has nothing at all to do with the nature of the problem.

The only people this will hurt are the patients stuck in the middle of the mess. This does nothing to prevent medical errors at all because it does not directly improve the practice of medicine nor the industries that support it.

On top of this who the heck will define preventable? Some commission? Bed sores can be preventable but many times they are not due to the nutrition status of the patient, their weight, and general health. But the government won't know this because they only look at codes they weren't there. Anyway, anyone who as been in medicine long enough knows that a lot of decisions are made between two different bad outcomes.

Finally, every patient signs a Consent stating the risks of things that occur...this includes infections, and such. Don't be suprised if the hospitals use this as a reason to stick the bill to the patient and try to get the money out of them which is what they already do when insurance refuses to pay even for the legit stuff.

 

[Flopotomist]

I wonder how far away we are from having institutions that simply stop accepting Medicare. If the reimbursement rates continue to decline, and more and more costs are shifted to the hospital, when does the hospital just say, "No, we can't admit your Grandmother here because we can't afford to accept the pennies on the dollar Medicare pays us...try down the street."

Of course we aren't there yet - but eventually it could be possible.

 

[Sol Rosenberg]

Hel-lo, have you considered the possibility that this is just going to be another example of cost shifting? Using the example of DVTs, you could order a 400 dollar u/s on every high risk patient and spend 40000 dollars finding a DVT. Congratulations, the system just paid 40 grand+ so the hospital doesn't have to pay for that DVT themselves. By giving the hospital such a ridiculously high incentive to avoid these few things you're creating even more inefficiency. Let's hear it for CMS!

Please tell me what DVT has to do with:

like leaving a sponge or other object in a patient during surgery

That seems pretty clear-cut to me. There should be no "cost shifting" because the doctor and/or hospital should've born the brunt of the cost for his/their error always. If there is any "cost shifting" in this case, it is because insurance companies have been billed erroneously for stuff like this in the past.

and providing a patient with incompatible blood or blood products.

To me, complications resulting from these actions are also pretty clear-cut the fault of the person who screwed-up and shouldn't be borne by insurance companies; however, a broad interpretation of the words "incompatible" and/or "products" can make this less clear-cut. I suppose your DVT reference makes more sense in this context.

 

[Sol Rosenberg]

I wonder how far away we are from having institutions that simply stop accepting Medicare. If the reimbursement rates continue to decline, and more and more costs are shifted to the hospital, when does the hospital just say, "No, we can't admit your Grandmother here because we can't afford to accept the pennies on the dollar Medicare pays us...try down the street."

Of course we aren't there yet - but eventually it could be possible.

IMHO, this is when we will start seeing major reform of the system (of whatever sort.) All the rhetoric (for example, by Presidential candidates right now) will amount to nothing substantial because the vast majority of people are still covered and have no major problems with their health care/obtaining health care. Once lots of docs stop taking Medicare (remember, as a group, old people have very high voter turnout) because of decreased reimbursement things will change.

 

[chrisisinnocent]

Please tell me what DVT has to do with:

That seems pretty clear-cut to me. There should be no "cost shifting" because the doctor and/or hospital should've born the brunt of the cost for his/their error always. If there is any "cost shifting" in this case, it is because insurance companies have been billed erroneously for stuff like this in the past.

It only seems clear cut to you because you have never actually provided patient care. It's an easy way to package it: "we just won't pay for Dr's screwups". Except a lot of things lumped in are complications due to taking care of very sick and often non cooperative patients, not mistakes.

 

[RockShox]

That seems pretty clear-cut to me. There should be no "cost shifting" because the doctor and/or hospital should've born the brunt of the cost for his/their error always. If there is any "cost shifting" in this case, it is because insurance companies have been billed erroneously for stuff like this in the past.

To me, complications resulting from these actions are also pretty clear-cut the fault of the person who screwed-up and shouldn't be borne by insurance companies; however, a broad interpretation of the words "incompatible" and/or "products" can make this less clear-cut. I suppose your DVT reference makes more sense in this context.

Well Sol another issue is the fact that they are...an insurance company (yes even medicare) this is what insurance is for. Does your fire insurance policy call you up and tell you that they will not pay for the damage because Fireman Bill hooked the hose up wrong and the house burned that much more? Does Gieco say "Oh you were reaching for a CD? Sorry that is preventable no money." The damn industry is called the insurance industry for a reason and it is supposed to make its living covering us for the UNEXPECTED and the damn STUPID. I pay for health insurance to also cover for the stuff that happens to me when the dumb nurse forgets to follow an order (which happens about 50 f&^king times a day) and something bad happens, not to tell the hospital to stick it and leave me holding the bag.

 

[cfdavid]

This is yet another ridiculous idea. I just don't get it. It's not like this is really going to impact patient care. Hospitals may not be perfect, but it's not exactly as if human error is something that occurs "on purpose". Penalizing hospitals for things that are beyond their control is yet another shift away from personal responsibility (of the patient), passing the buck over to the hospital. Bed sores, sure. But, some jack..ss becoming non-compliant and getting up for a stroll after repeated warnings and then "walking out of there with a broken arm" is quite another story. The hospital should just tell him to go to another hospital so they could treat it as a "new" case.....(kidding, sort of).

How about your average emergency room? You can't micro manage those fiascos..

I'm all about improved quality of patient care, and ways to minimize human error. But, the fact is that they DO (and will) occur. They can be minimized, but there are some "businesses" that are inherently riskier, and I'd say that medicine would be one of them.

 

[njbmd]

Moving to Topics in Healthcare for global input.

 

[chef_NU]

I wonder how far away we are from having institutions that simply stop accepting Medicare. If the reimbursement rates continue to decline, and more and more costs are shifted to the hospital, when does the hospital just say, "No, we can't admit your Grandmother here because we can't afford to accept the pennies on the dollar Medicare pays us...try down the street."

Of course we aren't there yet - but eventually it could be possible.

Best post on this thread. As long as there is a 2 tier system where 1 is funded by government, the government system will continue to cut reimbursement rates and, indirectly, quality of care. Imposing new requirements on hospitals and doctors will simply force healthcare providers to stop accepting Medicare because treating such patients no longer generates revenue. Of course, this also will have the side effect of FURTHER increasing private insurance premiums as hospitals and doctors try to offset the costs of the new requirements. So, in summary, arbitrary government cutbacks on Medicare reimbursement = more uninsured and more providers less likely to accept Medicare patients. GO POLITICIANS!!!!! BRAVO

 

[Sol Rosenberg]

It only seems clear cut to you because you have never actually provided patient care. It's an easy way to package it: "we just won't pay for Dr's screwups". Except a lot of things lumped in are complications due to taking care of very sick and often non cooperative patients, not mistakes.

I have only been commenting on the "blatant screw-up" part of the article the OP posted, because I was surprised that insurance EVER paid for blatant doctor's screw-ups (like leaving a sponge in a patient after surgery.)

Well Sol another issue is the fact that they are...an insurance company (yes even medicare) this is what insurance is for. Does your fire insurance policy call you up and tell you that they will not pay for the damage because Fireman Bill hooked the hose up wrong and the house burned that much more? Does Gieco say "Oh you were reaching for a CD? Sorry that is preventable no money." The damn industry is called the insurance industry for a reason and it is supposed to make its living covering us for the UNEXPECTED and the damn STUPID. I pay for health insurance to also cover for the stuff that happens to me when the dumb nurse forgets to follow an order (which happens about 50 f&^king times a day) and something bad happens, not to tell the hospital to stick it and leave me holding the bag.

Your analogies are flawed. If Firemen Bill, while fighting a fire at my next-door neighbor's house accidentally runs over my wife with his fire truck, he is damn well responsible for her death. Your auto insurance analogy is flawed, as well, and I really can't think of an analogous situation, beause it doesn't involve a 3rd party (i.e. the doctor.) My analogy is when you bring your car into the mechanic for a warranty repair. If the mechanic breaks something (it's undisputably his fault, like leaving a sponge in a patient after surgery) while performing the warranty repair, HE (or the shop that he works for) pays for fixing what he broke. He doesn't (or at least isn't supposed to) bill the factory warranty to fix what he actively broke -- it's on him (or the shop.) Please explain to me how this is different. Please also remember, I was only talking about the part of the article that spoke about Medicare not paying for:

"serious preventable events" like leaving a sponge or other object in a patient during surgery and providing a patient with incompatible blood or blood products.

NOT the part that talked about:

"conditions that could reasonably have been prevented."

Among the conditions that will be affected are bedsores, or pressure ulcers; injuries caused by falls; and infections resulting from the prolonged use of catheters in blood vessels or the bladder.

....which I agree is bull****.

EDIT: Another problem I have with this is that I consider billing an insurance company for correcting a blatant screw-up (leaving a sponge in a surgery patient) double billing. Personally, I would not consider the procedure complete until all cleanup (or at least the part that involves removing all equipment from the patient) is done. The doctor/hospital billed the insurance company for the complete procedure the first time around, and then want to bill again for the cleanup later, essentially double billing for the "cleanup" part. I think it should be on the doctor/hospital to provide the services that they billed for the first time around. In "Fireman Bill" terms: Say you paid Fireman Bill on a fee-per-fire basis. He comes to fight a fire in your living room, but leaves before it is completely put out. You expect him to come back and finish putting out the fire without having to pay him again. Duh. The more difficult question/problem occurs when Fireman Bill comes out, puts out the fire in the living room, but a smoldering ember subsequently starts a fire in the bedroom. I am not arguing whether or not "Fireman Bill" should get paid twice in this situation.

 

[docB]

We're getting bogged down because the CMS list presented a spectrum of stuff. For the sake of discussion I'd say most people think that leaving stuff in someone's belly is bad and falls toward the shouldn't be covered end. Even that's debatable because it is a known complication and nobody's perfect but there it is. Think more about the fact that every person who gets a UTI within some time frame after a foley (a week, a month, a year, how long will it be CMS?) will be uncovered.

This will create a ton of CYA. Prophylactic antibiotics for anyone with a foley, poseys for all demented patients, nursing homes refusing to accept patients with bedsores, etc. CMS thinks it can drive the hospitals to hire more staff to carry bedpans, assist patients out of bed, turn the patients every hour etc. Anyone in clinical medicine knows that won't be happening and that the hospitals will find the cheapest way out which won't be better patient care.

Here's what I honestly expect to come from this. There will be some byzantine criteria list you have to do to justify a foley. Antibiotics will be "encouraged" during and post foley. All patients will be limited to getting out of bed with assist. Any who get up without assist will be poseyd or told that by getting up they are doing something AMA. The docs will be forced to write for more PT/OT evals and air mattresses and so on. Remember that if we write for a ton of extraneous crap before there's a problem it'll be covered if there's an order, no so if the problem develops.

All of these things turn into a big shell game. Nothing gets better but the orders and cash flow just change patterns.