18 April 2008

Redefining Never

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.

I was going to make these arguments and more, at length and with lavish attention to detail. But I'm not going to. What I would rather do is point out is the fundamental dishonesty which underlies this initiative.

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.


  1. "This is cost containment masquerading as quality."

    I had the same thought. Not that we shouldn't (and most of us do) try to not have complications, but ......

    Anyway, good post.

  2. I have to say, being in primary care I have been largely sheltered from this idiocy. I find it hard to imagine that this is anything other than an excuse to not pay and therefore save money. It is a poor excuse for shafting doctors and hospitals in the garb of self-righteous "save the patient from bad doctors/hospitals" rhetoric.

    While this does not directly affect my specialty, I know it is but a matter of time before this insanity spills into outpatient settings.

    I guess this means that we need to continue practicing so we can become professional bowlers if the doctor thing doesn't work out.


  3. And I am SO glad I got out of vascular ultrasound. Now that DVTs occuring after admission will not be reimbursed I see even more vastly overused compression ultrasound exams (at about $1000 a piece) and possibly over-use of anticoagulants leading to paradoxical spike in thrombocytopenia.

    Of course my crystal ball could be on the fritz...

  4. Can you imagine the hissy fit that would be pitched if they tried to make this work both ways?

    "Oops, you didn't pay for this treatment in a timely fashion. Now you have to pay DOUBLE."

    "Uh-oh, typo in the code AND you filed it to the wrong patient because of a similar name. That's gonna cost you 20 large!"

    It makes as much sense as the original idea -- none at all.

  5. Just wanted to say, love your logic! You are so right on.

  6. The greater problems with health care in the US, are

    Quality is (overall) amazing; it is the least of the concerns here. I agree that this is a thinly veiled ruse to cut costs. It would be less insulting to be honest and straightforward.


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