In The Pipeline

I learned from the WSJ today that CMS is once again proposing rules to refuse payment for services rendered.  I talked about new helmet laws in hospitals and how a magic fairy dust is the answer in months past.  Now comes word that 2009 may introduce:

Section 5001(c) of the Deficit Reduction Act (DRA) of 2005 required the Secretary of the Department of Health and Human Services to select at least two conditions that are: (1) high cost, high volume, or both; (2) identified through ICD-9-CM coding as a complicating condition (CC) or major complicating condition (MCC) that, when present as a secondary diagnosis at discharge, results in payment at a higher MS-DRG; and (3) reasonably preventable through application of evidence-based guidelines.  The law further required hospitals to begin reporting on claims for discharges, beginning October 1, 2007, whether the selected conditions were present on admission (POA). 

PROPOSED REVISIONS AND ADDITIONS TO THE HAC LIST FOR FY 2009

 

CMS is proposing to add an additional nine categories of conditions that when acquired in the hospital will no longer lead to higher Medicare payment.  CMS proposing to select:  surgical site infections for certain elective procedures, hypoglycemic coma, collapsed lung due to medical care, ventilator-associated pneumonia among other conditions.  In addition, CMS is proposing to create new codes to better identify two conditions that were previously selected:   foreign object retained after surgery; and pressure ulcers. 

They don't list them as "never events"  this time.  Rather, they are "hospital acquired conditions".  And the proposed rules state that these conditions and others listed here can't be used as complicating conditions or major complicating conditions.

• iatrogentic pneumothorax
• deep venous thrombosis and pulmonary embolism
• delirium.  yes folks, that's right.  Delirium.

So the Medicare National Bank says they won't pay extra for these "complications"  because it's not considered quality.  What a bunch of crap.

Let's look at the proposal.  CMS links to an "evidence" based guideline for iatrogenic pneumothorax here.  There's really nothing evidence about it.  Simply stated, the top three causes of iatrogenic pneumothorax are central line placement, thoracentesis, and transthoracic needle aspiration.  Pleural and lung biopsies and ventilator complications round out the rest.  The last time I checked every single one of these is a complication of the procedure that is listed on the informed consent.  To state they are hospital acquired and can't be listed as a complicating illness is like me investing all my money in the stock market with a guarantee that the value will never go down.  Complications are a part of illness and to list them as hospital acquired instead of illness acquired further removes managed expectations from the equation of illness and does a disservice to families everywhere.   Listing it as a hospital acquired condition will further reinforce on families that it is malpractice and should be financially rewarded.  Simply stated, sick people get sicker.  Sick people have complications of illness.  Iatrogenic pneumothorax is one of those. I would like to know if a patient developed a pneumothorax at one hospital as a result of ventilator barotrauma in an end stage COPD patient,  that needed transfer to a higher level of care,  will the accepting hospital get paid for that complication?  If so,  how can CMS justify paying one hospital, and not another.

Deep venous thrombosis and pulmonary embolism.  I can understand the intense need to cover all patients with risk factors.  I am on the committee at our hospital.  I was invited to the annual SHM meeting in San Diego earlier this month to describe the efforts going on at our hospital to prevent venous thromboembolism.   My problem with categorical refusal of payment is that illness happens all the time, inspite of all attempts at prevention.  Some times you can't use anticoagulation.  Some times you can't use sequential compression devices.  Sometimes you can't use either do to surgery, or bleeding complications.  Should hospitals be penalized for practicing evidence based medicine by eating the cost of bad outcomes?  According to CMS policy,  VTE as a hospital acquired condition cannot  be considered a complicating condition or a major complicating condition.  Let met tell you.  This is exactly what they are.  Their basis for the evidence is the 2004 Chest guidelines.  Unfortunately,  I couldn't find anywhere in this entire article that stated following these guidelines would prevent 100% of hospital acquired VTE events.  So again I ask,  how can you deny payment for events that occur in spite of evidence based practice?  And what happens if a patient develops a VTE event at one hospital as a complication of their illness that results in a transfer to a higher level of care.  Will the accepting hospital receive payment for that hospital acquired event.  And if so,  how can you justify one hospital receiving payment and not another.  Also, what happens if a patient undergoes coronary artery bypass grafting at the physician owned specialty hospital.  Collects to $30K DRG.  Provided (or even consider that they failed to provide) appropriate VTE prophylaxis while hospitalized.  Discharges the patient on post op day 5.  And the patient shows up 3 days later in my ER with massive bilateral pulmonary embolism and DVT.   Hospital acquired.  Right?  Who pays for this new seven day hospital stay in the intensive care unit.  Does the MNB pay my hospital for a complicating condition.  Do they say no?  Does my hospital have to sue the physician owned cardiac center to get paid for this "hospital acquired" event.  I can't wait to see how this plays out.  It's going to get juicy.

Then there is delirium.  Just about every old sick person will get delirium at one point or another during their hospitalization.  What does CMS say about the evidence based guidelines to prevent delirium?    Interestingly,  some studies showed not reduction with interventions .  Some only mild reductions in interventions for delirium. In their own words they state:The literature for delirium prevention studies is small, and the methodologic quality of many studies is poor.  In other words.  It's not preventable.  And if it's not preventable, how can it not be paid for.  Instead of calling it what it is,  a complication of illness, we need to call it a complication of hospitalization and stop paying for it.  We are creating unmanaged expectations.  It's insulting to all the nurses, doctors, technologists who work hard every day to give great patient care.  Only to be told that it's our fault.  The only full proof treatment of delirium is death.  And I can accept that as the truth.

Quality is good.  Paying for quality is good.  Not paying for complications of quality care should be considered shoplifting. 

I fear we are already heading down that slippery slope of refusing to pay for care related to complications of illness.  Delirium is just the start.  Look out for acute renal failure, myocardial infarction, gastrointestinal bleed, stroke,  acute respiratory failure, cardiac arrest,   The list of any numerous complications that come with being old and being sick and in the hospital.I am waiting for the day that physician services will be denied for caring for complications of hospital acquired illness.  That's going to get messy.  You think you have an access problem now.  Just wait.   Labeling  complications of illness as hospital acquired, especially when evidence based guidelines are followed, is unreasonable, irrational and failure to pay for it should be challenged to the highest courts.  Unmanaged expectations have replaced common sense.