Monday, August 20, 2007

Medicare announces they won't pay for complications - How the F*** is this going to work?

Something dramatic is about to hit health care practices in the United States. The Federal government has announced regulations such that Medicare and Medicaid programs will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.”.

This list will apparently include:

  • Injuries from falls in the hospital
  • Urinary tract infections
  • Surgical Site infections
  • Blood transfusion reactions
  • Re-operations for retained surgical instruments
  • Bedsores and pressure ulcers

While no episodes of any of these events is the goal of medicine, it is IMPOSSIBLE to achieve that for a number of reasons. Consider the inpatient population in many locations - older, more obese, more medical co-morbidities, etc....

Only a bureaucrat who's never worked in a hospital could think up a program that's all stick and no carrot to address these. It makes more sense to reward achieving benchmarks rather then to punish oft impossible goals. But even the "carrot" from the feds is usually rotten, as can be witnessed by their attempts to establish similar outpatient medicine practice guidelines under the concept of "pay for performance".

To offset planned medicare fee cuts, they recently had a small trial offering a small 1.5% bonus for compliance with electronic medical reporting and some clinical issues. At the end of the trial, almost none of the large primary care groups could meet the threshold for the bonuses despite spending substancial amounts of capital to upgrade infrastructure to do it. While quality may have been improved, these groups essentially took pay cuts to do it. Does that sound like a program which is going to get much enthusiasm for participating?

WARNING: Trainwreck ahead!

What's going to happen in the real world with the new program as I envision it?

There's going to be not so subtle exclusion of high risk patients from inpatient treatments whenever possible. There will also be tremendous pressure for hospitals to dissociate themselves from physicians who bring older, sicker patients to their facility. Also expect to see lots of dodgy urinary tract infections and phantom pressure sores documented on admission surveys, as apparently making a paper trail will shield hospitals from being left holding the bag.

This whole thing is going to get really ugly as these predictable responses occur. Just look at a report like this report which documents a 40% reduction in complications in specialty Orthopedic hospitals which cherry-pick healthy patients and tell me that the take home message isn't to avoid sick patients! Want to make your catheter-related UTI rates better? Just don't put catheters in elderly patients and let them pee on themselves constantly. That's going to happen, WRITE IT DOWN!

Still not clear to me is what happens to Physicians who treat such complications. Will a Doctor get paid for treating a pressure sore or fractured hip from a fall? You don't even want to imagine the practical fallout from that scenario. I'll be looking forward to that report (scheduled to be released tomorrow) with interest.


Anonymous said...

What about non-compliance from patients, such as not walking, or doing their Incentive Spirometer post-op? I remember we'd do extra charting, as well as notify the dr (and chart that too) with non-compliant patients. Would Medicare's new policy fall under any of those things, even with documentation?

I also remember a patient withholding some of her conditions/history and meds from a plastic surgeon to ensure she'd get her plastics combined with her medical surgery. She ended up with complications. Whose fault would that have been as far as Mecicare's new non-payment policy for complications?

Dr. Rob Oliver said...

I agree. It's going to get real confusing assighning "fault" for these things (with the exception of retained surgical sponges or instruments).

Pressure sores (which is something I treat from time to time) is a particularly ridiculous thing to suggest is a preventable event in all (or even most) instances. Old, obese, sickly, paralyzed, incapacitated, or malnourished patients get pressure sores despite nearly perfect nursing care often.

Anonymous said...

I was trained in Illinois as a CNA (certified nursing assistant). We learned that all these things that medicare is not going to pay for are all things that can be avoided by properly trained and careful nurses and nurse aids. Medicare will not be paying for falls that occur in hospitals because those people should not be walking by themselves, they should be ambulated properly and falls will not happen. They also won't pay for bedsores because nurse aids should be turning their patients enough so that bedsores won't happen. Though there may be some problems that stem from Medicare not paying for these accidents, I feel that there will be a lot less accidents because now the hospitals should be paying more attention to not let these things happen.