Surgical Diversions

I’ve been getting to the point lately that the system needs to undergo some catastrophic collapse before it will get better.

As the Happy Hospitalist says:

Here’s my position. It’s time to let the cuts stand. Congress should not reverse the 10.6% cuts that began in July 1st 2008. And here’s why: The financial mess we are in now is entirely a result of third party interference of the doctor-patient relationship.

He’s absolutely correct in the assessment that the doctors are to blame. If only we didn’t prostitute ourselves by signing some of these outrageous contracts it might be better.

I say let the cuts go through. Then soon, both doctors and hospitals will soon realize that they cannot afford to take care of patients for the contracted rates and might actually grow the brass ones to cancel all of their contracts, including Medicare.

In October, 2007 CMS (Medicare) proposed a list of eight preventable conditions that result in a prolongation and increase in cost of care to the hospitalized patient. These are what CMS terms **never events**. CMS is trying to couch this in terms of patient safety but if you look at the list, there are only a few of these items that are 100% preventable. It’s really less about patient safety and more about how CMS can cut reimbursement. Medicine isn’t an exact science and expecting it to act as one is irrational.

On April, 14 2008 CMS proposed additions to their **never event** list…

The HAC provisions in Medicare regulations required hospitals to begin reporting on their Medicare claims on October 1, 2007, whether certain specified diagnoses were present when the patient was admitted. The first eight conditions, which were selected last year because they greatly complicate the treatment of the illness or injury that caused the hospitalization, resulting in higher payments to the hospital for the patient’s care by both Medicare and the patient, were:

• Object inadvertently left in after surgery
• Air embolism
• Blood incompatibility
• Catheter associated urinary tract infection
• Pressure ulcer (decubitus ulcer)
• Vascular catheter associated infection
• Surgical site infection- Mediastinitis (infection in the chest) after coronary artery bypass graft surgery
• Certain types of falls and trauma

CMS is proposing to expand the list of conditions that need to be reported if present when a patient is first admitted and is seeking public comment on whether they should be added to the list in the final rule to be announced later this year. The list in the proposed rule includes:

• Surgical site infections following certain elective procedures
• Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)
• Extreme blood sugar derangement
• Iatrogenic pneumothorax (collapse of the lung)
• Delirium
• Ventilator-associated pneumonia
• Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)
• Staphylococcus aureus septicemia (bloodstream infection)
• Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)

Some of the biggest problems in this list are twofold.

1. Who’s to define things like derangement and what constitutes delirium?
2. If these are **never events** can someone please tell me how to avoid them 100% of the time?

All invasive procedures, and I include having a foley and being on a ventilator as invasive, carry risk. The risk is small but it exists and it is not zero. I seems what CMS is seeking to do is to transfer the risk from the receivers of medical care to the providers of medical care.

Personally, I think this list will ever expand and eventually hospitals and physicians will cease to be paid for any care arising out of these **never events**. When that starts happening, watch out. All of a sudden it will not make financial sense for hospitals and doctors to participate with Medicare.