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Monday, August 20th 2007

Who Pays For Mistakes?

As The Saying Goes: Learn To Put Your Shoes On The Right Feet Before You Do Brain Surgery

Next year Medicare will not pay for some hospital mistakes.

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.

In many ways this short report spouts things that seem like common sense but there are things to be worried about in this move. Before I ramble off into my complaints know that I’m relatively consumer oriented for a health care provider (or future one). I believe P4P can work in the right situation, I believe in transparency and quality measure reporting.

That being said I have problems with what little I know about this CMS move. Healthcare is not selling a television or even cooking a steak; it is sadly more like commissioning a piece of art. Try returning that painting. I’m not saying there shouldn’t be real standards or that health care can’t learn something from the retail world, but let’s not pull out ridiculous cliches like “the customer patient is always right” or try to stamp some sort of “satisfaction guaranteed” deal on healthcare.

It doesn’t work that way.

We can all agree that things like leaving sponges inside of patients is unacceptable. No one should get extra cash for creating work for themselves. But bed sores and line infections? The problem I have here is that the burden is on the hospital to prove they didn’t cause something by neglect.

[A vice-president for the AHA] said that some of the conditions cited by Medicare officials were not entirely preventable. Commenting on the proposed rules in June, the American Hospital Association said, “Certain patients, including those at the end of life, may be exceptionally prone to developing pressure ulcers, despite receiving appropriate care.”

This isn’t them documenting and defending a procedure they did in order to collect a fee. This is them trying to disprove something. Is that really where the burden should be? I don’t see how that can be justified.

I’m sure the new guidelines will have specific provisions but I doubt the bureaucratic mumbo gumbo can cover every scenario where there is decreased responsibility for a line infection – patient’s with neutropenic fever and other immunosuppression, etc.

That whine can be improved upon over time with work and compromise. A more base concern is the old unfair business practice bit. Seriously healthcare payers are a cabal, which would almost be damn near unacceptable in any other business sector. That’s fine for many cause they don’t think healthcare is a business in the first place. But from where I’m sitting this kind’ve unilateral step (which is sure to be followed by private insurers) is ridiculous.

I’m all for providers not getting paid for their mistakes. I’m all for providers reporting their mistakes. It promotes competition, potentially lowers costs (trust me that’s where CMS is coming from) and…secondarily, helps protect patients. Such transparency and competition on the payers side as well, however, would never allow them to make this kind’ve unilateral move.

Finally, I’m disturbed by the unilateral nature of this move further considering the subjective nature of it. Like most of health care we’re witnessing a benefit versus cost analysis here. There are plenty of things Medicare could spend money on to help reduce hospitalization complications. For example, they could limit the number of patient’s to a room. That would be expensive and the magnitude of benefit is questionable (although I think likely there) and so that doesn’t make the list. Mistakes in hospitals are major, major problems and financial pressure is probably the most effective way of influencing a downward trend in those mistakes but do you really want a government bueacracy deciding, semi-independent of the health care provider community, how far and how short they’re going to go in deciding how to cut down on nosocomial infections, wrong surgeries, etc.? I don’t.