From Roy at Health Care Renewal:
Federal health officials on Monday proposed adding dangerous blood clots in the leg and eight other conditions to the list of complications that Medicare won't pay to treat if they were acquired at the hospital.Included in this are, among others, Iatrogenic Pneumothorax and DVTs.
I was going to bitch and moan that this is stupid. But I'm not going to.
Not that it isn't wrongheaded and misguided. There are a lot of things not to like in this proposal. As Roy points out, using delerium as an example, there is no reliable way to prevent some of these "never" events, and that despite best efforts there will remain an irreducible incidence of these conditions.
The persistence of complications shouldn't preclude a certain condition or procedure from being targeted as a core quality measure. As Atul Gawande pointed out, central line infections can be largely though not completely eliminated, and there is good organizational quality research to back that up, which makes it reasonable for that to be a metric that should be focused on. Conversely, most simple iatrogenic pneumothoraces are caused by central line placement, thoracentesis, or lung biopsies. Sticking needles into peoples' chests is, from time to time going to puncture a lung; it is an inherent risk of the procedure. There is, to my knowledge, no comparable study or program to reduce the incidence of pneumothoraces after central line insertion.
Further, it is nonsensical to make peumothorax a facility quality indicator. If there is some quality component to this complication, it is in the skill of the practitioner who performs the procedure, not the facility. While well-developed programs to reduce ventilator-acquired pneumonia can be implemented by the facility, it is unclear to me how facilities might impact the skill of doctors putting in central lines, or surgeons performing biopsies.
CMS would have you believe that this is about quality and patient safety. Who can argue with those laudable goals? They are so revered as to be sacred, and with good reason. But don't be fooled. This is cost containment masquerading as quality. As we start to see more and more of these unpreventable "never" events proliferating, and more and more payors signing on to the concept of not paying for "errors" you will see that this is really about reducing the total amount that the big payors spend on the care of sick patients, and shifting the risk of caring for the critically ill onto care providers. It is also informative that CMS is focusing on payments to hospitals, which are much more expensive than the payments to physicians, despite the fact that physicians would theoretically be just as sensitive to payment reductions and are in a position to more directly improve the "quality" of care.
As quality -- a critical and praise-worthy mission -- becomes hijacked by financial considerations, we are seeing how quickly the dollars drive the real and sensible quality indicators off the rails. This is a compelling argument for keeping the two separate. If CMS needs to cut costs, then they should do so in a clear and transparent manner. Policies that are designed to improve care will be met with skepticism and resistance from physicians and hospitals, suspicious of the ulterior motivation of the payors, so long as these policies continue to link dollars to the complications. Quality metrics which are designed with an eye to saving money are more likely to save money than to save lives.
We haven't a hope in hades of stopping this runaway freight train, not with the current administration, and probably even less likely under its successor. It's too far down the tracks now, and too deeply embedded in the brainstems of the bureaucrats at CMS and TJC. At the least we should be sure to provide our feedback, and try to keep the quality metrics relevant and achievable. One link that should be prominently featured on every blog post that references this proposed rule is this:
This is at this time just a proposed rule, and the period for public comments is open until (I think) June 13. Click on the link and follow the instructions for "Comment or Submission" and enter the file code CMS-1390-P to submit comments on this proposed rule.
This link should take you directly to the appropriate page to leave a comment.