Thursday, April 17, 2008

Medicare new "No Pay" Conditions


Medicare/Medicaid covers about 45% of American health care through payment for the disabled and old folks. (I know, I know, "65 is the new 35", but you get Medicare anyway). The rules and payment strategies of Medicare are adopted by the entire industry, and what Medicare pays for and doesn't pay for, eventually is picked up by private insurers too.

Starting in 2008, Medicare has identified 7 conditions that they will not pay for if the patient gets them after they are admitted to a hospital. Some of them make good sense as a push for quality improvement and patient safety. These include blood incompatibility, objects left in after surgery and wrong site surgery. These events are 100% preventable. Others are difficult for even the best caregivers to prevent, like patient falls. Unless you tie a patient into bed (which will definitely affect your "customer satisfaction" scores), a wobbly person, somewhere, sometime, will fall.

Now Medicare has completely lost it with a list of additional "no-pay" errors. The new list, with my comments is below:
  • Delirium (this is ridiculous. There are so many causes for delirium that have nothing to do with the caregiver. Delirium is an altered state of consciousness that may require treatment, not sanction)
  • Surgical site infections following certain elective procedures (I'm OK with this one if they eliminate trauma, dirty wounds, or immune suppressed individuals, where infection may be unpreventable)
  • Legionnaires' disease (this can happen in an isolated case, with the origin of the bacterium being a mystery. If a hospital has an outbreak that affects many, the health department should investigate. One incidence may have nothing to do with hospital acquired infection)
  • Extreme blood sugar derangement (talk about vague. Too high? Too low?)
  • Ventilator-associated pneumonia (yes, preventable)
  • Deep vein thrombosis/pulmonary embolism (mostly preventable)
  • Staph infection in the bloodstream (I presume they are talking about MRSA. I do not think this is 100% preventable anywhere.)
  • Clostridium difficile infection (ridiculous. Anyone who is on antibiotics could get c.diff infection. Should we give up antibiotics in the hospital?)
  • Collapse of the lung from medical procedure (a small collapse of the lung is a known risk of placing central lines. These lines are placed in emergencies all the time to save lives in hospitals and the only way to prevent them is to transport the patient to a fluro Xray and do the procedure there. I would rather take the risk of a small lung collapse than die during delay and transport)
Medicare has a cost and financing problem. Refusing to pay caregivers for taking care of patients is a ridiculous and dangerous policy. These "no-pay" conditions need to be reevaluated pronto, using sound science and input from doctors and nurses that are on the ground day in an day out, caring for sick people.

33 comments:

Buckeye Surgeon said...

Is this for real? You've got to be kidding me. Surgical site infections, even for clean cases like breast biopsies and lipoma excisions still carry a wound infection rate of 1-3%. And pneumothorax after central line placement? And elevated blood sugars? And MRSA bloodstream infections? And C diff????? Do these people live on a different planet? We're nearing the danger zone of making it legitimate not to reimburse physicians for any complications whatsoever. What happens when the surgeon has to do an emergency colectomy for severe c diff? He/she doesn't get paid? It's absurd.

The Happy Hospitalist said...

Toni, I couldn't agree with you more. I gave my view on this yesterday titled, "In the pipeline"

job said...

tanks for the information, Dr. I appreciate your good work.

Anonymous said...

my wife said that now CMS is going to be collision only coverage like on the car.

Anonymous said...

A preventable HAI is a big problem in hospitals. How can you tell me that when someone gets legionella in a hospital that the hospital is not responsible. There is technology available today that will eliminate this pathogen from the water. I completely agree with the list and would like to see hospitals more accountable. In the situation with C diff - the hospital would be on the hook for treatment after a patient comes down with C diff. How is that so outrageous?

Anonymous said...

"Ventilator-associated pneumonia (yes, preventable)"

Really??? Just when was the last time you managed a vented patient anyways? One thing I will guarantee you is that if a patient is on a vent long enough, he/she WILL get a pneumonia.

My ideas said...

The government did something really smart here. Much of the spread of C. diff and MRSA is preventable. Granted, if you take antibiotics you can brew up c. diff in your own body; HOWEVER, that is not how much of this infection is spreading. Much of the rapid rise C. diff and MRSA infections is from picking up these bacteria from hospital surfaces and the like. Thus, common sense tells you that they're largely preventable. Based on my research into these infections, I have found a brilliant solution to hospital-acquired infections: steam cleaning. The products look like vacuum cleaners except they're made for hospitals, and they steam sterilize surfaces, bed rails, floors, and everything else. Steam kills everything, it is the temperature of boiling water. I am hopeful that the government's legislation will compel hospitals to buy these machines, because C. diff, for one, is not killed by standard hospital disinfectants. You have to use bleach, which many hospitals don't, and hence, the rapid rise of C. diff. NOBODY should accidentally pick up this infection; it should be completely eradicated from hospital surfaces. Hospitals, get your act together and get rid of this! Steam, bleach, whatever, just pick something that works and go with it.

Ashley said...

This is really an interesting post! I hope that Medicare would consider reevaluating the "no-pay" conditions. To find out what would be best to do for the sake of the sick people. Thanks for the post!

Ashley

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The medic care system leaves room for a lot of changes. Right now it is not great at all. We should take Canada as an example.

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