Prepare to be punished.

[Faebinder]

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So folks... we got a new list of things medicare wont pay for

Surgical site infections following certain elective procedures
Legionnaires' disease
Extreme blood sugar derangement
A collapse of the lung resulting from medical treatment
Delirium
Ventilator-associated pneumonia
Deep vein thrombosis/Pulmonary Embolism
Staph infection in the bloodstream
Disease associated with Clostridium difficile infection

Prepare for the worst. Wonder how will it affect residency.

 

[DrDawg]

This is the original list.

Bed-sores
Two kinds of catheter-associated infections
Air embolism, or bubbles of air or gas entering the bloodstream during medical procedures
Mediastinitis (infection of the area between the lungs) after coronary bypass surgery
Giving patients the wrong blood type
Leaving objects inside surgery patients
In-hospital falls

 

[Trifling Jester]

Prepare for the worst. Wonder how will it affect residency.

I'll tell you how. No reimbursement for "collapsed lungs from medical therapy" will eventually mean no unsupervised central lines or thoracentesis. The hospitals will screech to a grinding halt as they try to arrange for attendings to actually be present for those procedures to prevent the "never event." (not that the attending's presence would likely make a difference, but reasonable people are not implementing these changes)

-The Trifling Jester

 

[Amxcvbcv]

Not even in July? 😛

 

[Geri_Gal]

Legionnaire's Disease? Please.

Under the auspices of "patient safety", the government is pretty determined to cut health care costs in order to decrease their burgeoning debt. Though, this can lead to better hospital care (e.g. minimizing foleys, not snowing our elderly folks with benzos --> delirium), many of these so called "complications" can be a result of the patient's underlying disease. (e.g. "extreme blood sugar derangement", "delirium")

Most of these conditions occur in the sickest patients, e.g. ICU patients, medical patients with multiple comorbidities. It is IMPOSSIBLE to prevent staph aureus bacteremia or C. diff colitis in all patients. We must do what we can to minimize risk, but the government is not acknowledging that this risk is inherent in our treatment of disease. What is the logical conclusion of this proposed change? Hospitals will punt the sickest, poorest patients to already overburdened county/city hospitals. Residency training programs will need to fight/coax hospital administrations to allow their residents learning opportunities.

MOST IMPORTANTLY, the overall cost of care does not change! The burden is only shifted to the private sector. This does little to solve the real problems that exist in our health care system.

 

[WallowaWanderer]

]Surgical site infections following certain elective procedures
Legionnaires’ disease
Extreme blood sugar derangement
A collapse of the lung resulting from medical treatment
Delirium
Ventilator-associated pneumonia
Deep vein thrombosis/Pulmonary Embolism
Staph infection in the bloodstream
Disease associated with Clostridium difficile infection[/URL]

Prepare for the worst. Wonder how will it affect residency.

And patients with these conditions will be transferred to the local managed care administration office for treatment.

 

[DrDawg]

I'll tell you how. No reimbursement for "collapsed lungs from medical therapy" will eventually mean no unsupervised central lines or thoracentesis. The hospitals will screech to a grinding halt as they try to arrange for attendings to actually be present for those procedures to prevent the "never event." (not that the attending's presence would likely make a difference, but reasonable people are not implementing these changes)

-The Trifling Jester

Most of these procedures are not reimbursed as it is, at least here. All those lines that you put it are for free, as are the chest tubes unless an attending is present. The big difference may come in procedures done by other specialitist (thoracentesis, and lung biopsies). We typically admit radiologies post biopsy pneumo because we will put the tube in. But if we don't get paid will we still admit? Will this eventually extend to other known complications? Perf colon after colonoscopy, ect?

 

[yaah]

Legionnaire's Disease? Please.

.

Yeah, WTF is up with that? Who was lobbying for that? It's a hard diagnosis to make - do you only NOT get reimbursed if it's documented Legionnaire's disease? Pretty random.

 

[elwademd]

Most of these conditions occur in the sickest patients, e.g. ICU patients, medical patients with multiple comorbidities. It is IMPOSSIBLE to prevent staph aureus bacteremia or C. diff colitis in all patients. We must do what we can to minimize risk, but the government is not acknowledging that this risk is inherent in our treatment of disease. What is the logical conclusion of this proposed change? Hospitals will punt the sickest, poorest patients to already overburdened county/city hospitals. Residency training programs will need to fight/coax hospital administrations to allow their residents learning opportunities.

perhaps nobody admits the patient. perhaps they're just stabilized in the er (emtala) and sent home...

at some point in this country, we'll address the fact that funding/finances aren't infinite, and that however difficult it may be, we need to have finite funding, and figure out what's important to pay for and what isn't.

 

[Tired]

I predict a dramatic dropoff in the incidence of Legionnaires, iatrogenic PTX, etc.

 

[JackBauERfan]

Yeah, WTF is up with that? Who was lobbying for that? It's a hard diagnosis to make - do you only NOT get reimbursed if it's documented Legionnaire's disease? Pretty random.

legionnairs is a joke compared to TB, TB would kick legionnair's butt...maybe thats why they pay for TB but not legionnaire?

 

[docB]

I predict a dramatic dropoff in the incidence of Legionnaires, iatrogenic PTX, etc.

Do you mean you think this jackasstic program will work by actually decreasing the incidence of these these complications or that people will quit diagnosing things they can't get reimbursed for?

 

[Faebinder]

Do you mean you think this jackasstic program will work by actually decreasing the incidence of these these complications or that people will quit diagnosing things they can't get reimbursed for?

Medical PTX will drop a lot. People will see it and not call it.

Medicare is basically saying they wont pay for readmissions of these problems. If your patient got CDif then it's your fault for giving antibiotics regardless of the fact that the patient needed them or not.

They are attacking the WRONG Diseases. The respirator induced pneumonia may be a step in the right direction. I feel medicare should look at the overall status and prognosis of the patient to deny payment rather than the disease.

80 y/o with 2 organ failures and then got a pneumonia on the vent... sure, time to let go. 40 y/o lost a lot of blood in surgery, kept on the vent, got a pneumonia on the vent... different picture altogether.

 

[docB]

Medical PTX will drop a lot. People will see it and not call it.

Medicare is basically saying they wont pay for readmissions of these problems. If your patient got CDif then it's your fault for giving antibiotics regardless of the fact that the patient needed them or not.

They are attacking the WRONG Diseases. The respirator induced pneumonia may be a step in the right direction. I feel medicare should look at the overall status and prognosis of the patient to deny payment rather than the disease.

80 y/o with 2 organ failures and then got a pneumonia on the vent... sure, time to let go. 40 y/o lost a lot of blood in surgery, kept on the vent, got a pneumonia on the vent... different picture altogether.

It's gonna be hard to avoid the PTX issue. If you drop a lung the radiologist will call a PTX and you've gotta put in a chest tube. That one will be hard to hide. Take Cdiff for example. If someone has a patient who develops diarrhea after a course of antibiotics they could hypothetically not do cultures and just start the Flagyl PO. They could never diagnose the verboten "C Diff colitis" and just treat "infectious diarrhea" or generic colitis or dehydration for those extra days.

 

[Tired]

Do you mean you think this jackasstic program will work by actually decreasing the incidence of these these complications or that people will quit diagnosing things they can't get reimbursed for?

The latter. All of a sudden 85yo men with C Dif will get diagnosed with Trich instead as justification for courses of flagyl. The indication for chest tube placement will be empyema, rather than pneumothorax. This will continue until the first time someone goes to jail for medicare fraud.

 

[Winged Scapula]

I dunno about you guys, but I'm gonna stop diagnosing all those patients with Legionnaires.🙄

 

[Faebinder]

It's gonna be hard to avoid the PTX issue. If you drop a lung the radiologist will call a PTX and you've gotta put in a chest tube. That one will be hard to hide. Take Cdiff for example. If someone has a patient who develops diarrhea after a course of antibiotics they could hypothetically not do cultures and just start the Flagyl PO. They could never diagnose the verboten "C Diff colitis" and just treat "infectious diarrhea" or generic colitis or dehydration for those extra days.

Ya, no kiddin.. already in CRS we dont even culture if someone is coming in with bloody diarrhea... flagyl and levaquin at the door... and if they cant tolerate po then it's straight up cubicin.

 

[Geri_Gal]

Ya, no kiddin.. already in CRS we dont even culture if someone is coming in with bloody diarrhea... flagyl and levaquin at the door... and if they cant tolerate po then it's straight up cubicin.

Does anyone know if there is a way to protest this change?

Unfortunately, if this is passed, we as physicians will look bad. The public does not understand that these conditions are not necessarily "complications" but are risks inherent in treatment and in disease/underlying host status. We cannot be made the scape goats for a failing health care system.

And Legionnaire's is just ridiculous. Are they implying that this infection is commonly acquired IN the hospital?

 

[Strength&Speed]

The latter. All of a sudden 85yo men with C Dif will get diagnosed with Trich instead as justification for courses of flagyl. The indication for chest tube placement will be empyema, rather than pneumothorax. This will continue until the first time someone goes to jail for medicare fraud.

LOl, trich in an 85 yo man? Do you think this will happen a lot, or how about ever? I dont think its believable, nor frankly, even possible to say anyone has trich without some corroboration. and you can't say an empyema if there's no fluid. I understand people may bend the rules, but these scenarios are a tad implausible.

Frankly, hospitals are dangerous *** places. I don't see a problem with them not paying for falls and the like.

 

[michaelrack]

Medical PTX will drop a lot. People will see it and not call it.

Medicare is basically saying they wont pay for readmissions of these problems.

So if a patient is readmitted with one of the listed problems, presumably the hospital won't get paid. What about the docs? Can docs still bill and collect eval and management codes for treating these pts?

 

[Strength&Speed]

LOl, trich in an 85 yo man? Do you think this will happen a lot, or how about ever? I dont think its believable, nor frankly, even possible to say anyone has trich without some corroboration. and you can't say an empyema if there's no fluid. I understand people may bend the rules, but these scenarios are a tad implausible.

Frankly, hospitals are dangerous *** places. I don't see a problem with them not paying for falls and the like.

That isn't to say some of these rules aren't a little confusing. Legionnaires? Why? I don't understand that. But there is little excuse for VAP, urinary caths being left in too long, etc. So, you might not like it, but these will make some hospitals safer. The pneumothorax issue i don't care for too much, because that's going to happen anyway. I don't see how them not paying for it will change the rates of medical PTX. To me that's mostly punitive. But, the point is they are trying to make hospitals safer by making hospitals reduce the rate of preventable events. That's not so bad, and frankly, needs to happen.

I do not want these rules to punish residents, who are already burdened enough. But hospitals do need to be safer.

 

[docB]

Does anyone know if there is a way to protest this change?

You could opt out of CMS, never see any M&M patient and never see inpatients. Otherwise no.

Unfortunately, if this is passed, we as physicians will look bad.

It's already been passed. CMS doesn't ask, they do. If you haven't figured out how much CMS cares about doctors yet it's time. They don't.
If you want to get really angry have a look at the next bit of insidious horror CMS will be crapping all over us in yet another attempt to avoid paying their bill while appearing to be acting in the interest of patients:
http://www.hcahpsonline.org/

The public does not understand that these conditions are not necessarily "complications" but are risks inherent in treatment and in disease/underlying host status. We cannot be made the scape goats for a failing health care system.?

We always are the scapegoats. This time will be no different. Next time won't either. Now the time after that... nope, no change, we're still screwed.

And Legionnaire's is just ridiculous. Are they implying that this infection is commonly acquired IN the hospital?

No. They're saying they don't want to pay for that anymore. Wait 'til they don't want to pay for chest pain.

Everyone who wants socialized medicine take note. After we socialize every patient will be a CMS patient.

 

[Tired]

So if a patient is readmitted with one of the listed problems, presumably the hospital won't get paid. What about the docs? Can docs still bill and collect eval and management codes for treating these pts?

No pay for readmit. What about in house? I have yet to see a readmit for PTX after chest tube, but my first couple pulls were quick collapses.

 

[Faebinder]

So if a patient is readmitted with one of the listed problems, presumably the hospital won't get paid. What about the docs? Can docs still bill and collect eval and management codes for treating these pts?

It's gonna be a fight. You can imagine some dumb coder deciding you are treating the disease not-billable disease but infact you are doing something to treat the billable disease... and as a result your bill wont get paid.


I predict seeing more collection in physician's account as billed procedures/treatments/management wont get paid when the coder decides you are treating something they dont pay for.

Oh ya, the list will expand in the future to include most adverse events and complications.

 

[Southpaw]

They are attacking the WRONG Diseases. The respirator induced pneumonia may be a step in the right direction. I feel medicare should look at the overall status and prognosis of the patient to deny payment rather than the disease.

80 y/o with 2 organ failures and then got a pneumonia on the vent... sure, time to let go. 40 y/o lost a lot of blood in surgery, kept on the vent, got a pneumonia on the vent... different picture altogether.

Treat the 80 year old. We gave the intervention, treat the complication we caused regardless of circumstance.

Regardless of overall status of pt, prognosis, or whatever else, if we give an intervention then we should treat the complication we caused.

 

[DrDawg]

It's gonna be a fight. You can imagine some dumb coder deciding you are treating the disease not-billable disease but infact you are doing something to treat the billable disease... and as a result your bill wont get paid.


I predict seeing more collection in physician's account as billed procedures/treatments/management wont get paid when the coder decides you are treating something they dont pay for.

Oh ya, the list will expand in the future to include most adverse events and complications.

Do you think that this (no reimbursement for complications) will push a larger # of patients into the nonoperative management plan?

 

[MOHS_01]

This "new way of doing things" is not that new -- it is a rehashing of the original DRG and capitation philosophies. In essence, it is a risk transfer to the providers, hospital and physician alike. It will open a Pandora's Box, I fear, due to the very question asked by Dr Dawg.

 

[Geri_Gal]

Everyone who wants socialized medicine take note. After we socialize every patient will be a CMS patient.

This is true, but at that time there will be no (or very little) private industry to blame/leave expenses for "complications". CMS would have to accept responsibility for those patients.

Or maybe it would invest in these...

/only kidding
//...sort of

 

[docB]

This is true, but at that time there will be no (or very little) private industry to blame/leave expenses for "complications". CMS would have to accept responsibility for those patients.

And the government has traditionally been so good about accepting responsibility for things.

 

[Coastie]

I have a list:

Crack head chest pain. After the 3rd presentation with a positive DOA, you are sent to the street. Flash pulmonary edema buying you your 3rd ICU admission in a month? Sorry. Hundreds of millions saved.

Drunk man aspiration pneumonia: 3 strikes and you're out. Difficult placements, and plenty of co-morbidities. Hundreds of millions saved.

Non-compliant hemodialysis, with line infections, icu admissions, medications, and transplants lost to follow up: do you guys realize the money we lose each year to this alone? Billions.

Illegal Immigrants: When will we wake up and realize that this is a huge problem in the southwest, texas, and parts of the southeast? Billions saved.

CT and MRI imaging for the uninsured "rule outs": Mid-hundred of millions saved for testing done to CYA.

Trial Lawyers: 'Bout time to crack down on these guys who force us to practice defensive medicine totaling in the BILLIONS.

Reduce mandates on physicians with regards to billing and charity work: Allow physicians to do charity work within their offices despite medicare exclusive contracts, and write off the costs with good samaritan malpractice coverage. Overall savings to the system: Billions.

The "one extra day" in the hospital because the social worker demands a perfect placement for a non-compliant bounceback patient: Intern year alone I stopped counting at 200 total lost days due to this. Total costs lost to medicare observed by one intern for these days, due to ancillary staff issues, CYA medicine, non-compliant patients, and all complete with co-morbidities and complications stemming from these extra stays which resulted in even more stays and procedures? Easily $1 million dollars. How many interns are there in America now-a-days?

So folks... we got a new list of things medicare wont pay for

Surgical site infections following certain elective procedures
Legionnaires' disease
Extreme blood sugar derangement
A collapse of the lung resulting from medical treatment
Delirium
Ventilator-associated pneumonia
Deep vein thrombosis/Pulmonary Embolism
Staph infection in the bloodstream
Disease associated with Clostridium difficile infection

Prepare for the worst. Wonder how will it affect residency.

 

[docB]

I have a list:...

I'll sign your petition.