Sunday, August 26, 2007

Medicare won’t pay for mistakes?

This has been covered heavily in the blogs recently. I’ve been mulling over whether to weigh in these last few days, and up to now things have been too hectic for me to give this topic sufficient time and depth.

Despite the simplistic media spin this isn’t a simple matter of whether Medicare will “pay for mistakes”. It’s not as if Medicare even pays for the all the appropriate hospital care patients actually get. Medicare hasn’t done that since the advent of DRGs in 1983. That’s not a joke or an abstraction; it’s true in the real world, as evidenced by the fact that hospitals lose money on Medicare inpatients.

For a glimpse of what’s really going on check out the primary sources. Here’s the full text of the regs from the Centers for Medicare and Medicaid Services (CMS). (Warning: large pdf with over 2000 pages containing difficult to decipher alphabet soup and jargon along with innumerable rules inventing an untold number of crimes. Those who want “Medicare for all” take note).

Since Medicare doesn’t even pay for all necessary and appropriate hospital care what is meant by “not paying for mistakes”? As the CMS press release explains, the new rules actually constitute a complete revamp of DRGs including, among many other changes, a list of newly designated hospital complications which can no longer be coded to enhance the DRG payment. Thus hospitals can no longer recoup losses sustained as a result of certain complications which occur during hospitalization.

CMS promotes the new measure as a quality incentive and a means to more “accurate” reimbursement. It’s been widely applauded in the popular media. It is simplistically argued that Medicare should stop rewarding hospitals for preventable complications. That argument doesn’t stand up to close examination. The new policy is unfair on more than one level. First of all, DRG payments under Medicare’s Inpatient Prospective Payment System (IPPS) have never rewarded hospitals for appropriate or even perfect care, let alone for mistakes. The IPPS is an under funded mandate for hospital care of the sickest and most complex patients. Like a hidden provider tax it has penalized rather than rewarded hospitals for years. With its new policy CMS is merely stiffening the penalty.

Implicit in the policy of penalizing hospitals for adverse events is the idea of blame. CMS attempts to justify its position by citing prevention guidelines for each of the conditions listed. The newspaper spin is that potentially preventable adverse events such as falls and decubitus ulcers are medical mistakes which hospitals have been “blasé” about preventing. To anyone with experience in the care of hospitalized patients that’s patently absurd. Orac did a masterful job of exposing the absurdity in a recent post:

I know what some of you are thinking, particularly those less inclined to like doctors. You're probably thinking: Greedy doctors! No wonder they oppose something like this. There's just one problem. Most of the items on the list, although potentially preventable, are not 100% preventable even under ideal conditions. Take pressure ulcers (bedsores), for example. There are certainly nursing care interventions that can greatly decrease the risk of pressure ulcers, but no intervention will reduce that risk to zero. I've seen patients where everything was done right, the patients were turned frequently and placed on the latest beds designed to minimize pressure, who still got ulcers. Remember, Christopher Reeve, who presumably got the best skin care available after he became quadriplegic, died from sepsis due to an infected pressure ulcer.

By CMS and popular media standards, apparently, Reeve’s death was the result of a medical mistake. Pressure ulcers will never be eliminated until someone figures out a way to levitate patients. That would be the ultimate in woo. It’s beyond the pale even for the alties. (Well, most of them, anyway).

The reality is that Medicare’s IPPS forces hospitals to play a game in order to survive. It’s a game with many dimensions in the areas of coding, documentation, case management and cross subsidization. Hospitals that can’t play the game close. When other hospitals get good at the game over time Medicare changes the rules. From where I sit the impending rule change is just the latest of many vagaries of the Medicare game over the years.


Trisha Torrey said...

You're right, Dr. RW. Some of those "mistakes" aren't mistakes at all. Instead, many of them come under the "neglect" category.

Like the neglect of not turning a patient often enough. Or the neglect of not washing one's hands before visiting an at-risk for MRSA patient.

Healthcare practitioners and facilities are among the few that get paid regardless of whether they are wrong or right. Granted, there will be times that the damage to a patient won't be reimbursed by Medicare even though the hospital's personnel are not at fault, but prior to Oct '08, the times those hospitals will have been reimbursed when they should not have been rewarded for errors and neglect, will have already allowed them to get away with these crimes on patients for too many years.

The buck is going to stop at the hospital level. and the bucks are going to stop. period.

Trisha Torrey

R. W. Donnell said...

Let's start with your premise that hospitals should be penalized for neglect and crimes. That begs the question of how possible instances of neglect and crime should be documented and adjudicated. You do believe they should be, and that the process should be fair, don't you?

Many falls, pressure ulcers and infections occur in spite of good care. The new Medicare policy implies that all such outcomes are somebody's fault, as if the hospital is guilty until proven innocent. Do you subscribe to that view? How, then, if hospitals are to be penalized, can such events be adjudicated fairly?

spike said...

If you look at what Virginia Mason is doing with their Lean initiatives and compare it to the rest of the hospital industry, it's pretty easy to see that no, doctors and hospital administrators are not doing everything they can to prevent waste, unnecessary procedures, and quality of care breakdowns.

But it's not that the caretakers are greedy or evil or anything like that. Generally, it's that they haven't taken a hard look at their processes to reduce errors. Process improvement is difficult stuff and I imagine it's not taught enough in Medical Schools, Nursing Schools or Health Administration programs. Therefore hospitals continue to be plagued by flawed processes carried out by people with the best of intentions. It doesn't matter how caring or knowledgeable or considerate the nurse or doctor is. If they're in a bad process, they're going to get bad results. How many hospitals have sincerely attempted Six Sigma, Lean or other quality initiatives proven to reduce quality errors? Based on the sheer volume of medical errors in America, I would say not enough.

I would argue that monetary incentive of this kind might be the only way to get hospitals to truly take medical errors seriously.

Anonymous said...

So as a health care professional this infuriates me! It is not necessarily the care that one gets at the hospital that dictates whether or not one gets a bedsore. Lets think about this...MANY people come into the hospital with pre-exisiting conditions which makes them more at risk for a bedsore. Even if EVERYTHING is done for that patient to reduce the risk and try to prevent a bedsore they can still get one. Lets take for instance an obese patient who goes in for cardiac surgery and needs cardiopulmonary bypass (heart/lung machine). There are things that are going on with that patient's body well before they get to the hospital. Low perfusion to the skin, etc. Now why would a hospital want to treat that patient knowing that they are at a high risk for a bedsore and having the surgery basically ensures they get a bedsore? Why take that on and not get reimbursed for it? I think that there should be some system in place that takes into consideration pre-existing conditions in a patient that may lead to a bedsore not matter what. I dont think we should chalk it up to poor education of our health care workers- believe me, they all get the same education and most of it is geared towards prevention- pressure ulcers included. Maybe its the LACK of health care workers, maybe we should start looking at the companies that engineer expensive equipment for prevention of these bedsores that don't necessarily do their job. I think there is SO much more that goes into preventing bedsores than someone sitting at a desk realizes, and for those people to dictate who should get reimburse for what is absurd! Maybe we should start standing behind our healthcare providers and start pointing fingers at the poeple who make these policies and do systems management.