Medicare’s decision to stop paying for the extra costs associated with eight “preventable” conditions is not going over well. When one messes with someone’s income, they tend to get fussy. Nevertheless, should hospitals shoulder entire cost of such services? Are all of these truly the responsibility of the hospital?
To set the stage, the eight conditions are: patient falls, pressure ulcers, urinary tract infections, vascular-catheter-associated infections, mediastinitis, air emboli, removal of objects left in the body during surgery, and injury caused by use of incompatible blood products. Some are clear, preventable errors. But some — such as pressure ulcers and UTIs – may not be. Responding to an article on MedPage Today, one commenter wrote, “Even people who are not medical professionals understand that complications can occur naturally in spite of a hospital’s best efforts. I think the best solution would be for Medicare to pay a fixed percentage of the costs associated with a condition based on estimates of how often it could reasonably be prevented. So if it’s estimated that 20% of UTIs could be prevented, Medicare would pay 80% of the normal costs associated with UTIs when they’re contracted in hospitals.”
The change in Medicare rules will not occur for another year — October, 2008. That allows time for changes. Clearly, the theme running through healthcare is this: services should be necessary and appropriate, given the current state of knowledge. Call it evidence based medicine, call it cookie cutter medicine. There is too much going on that is known not to work, and too much going on that hurts, and too much NOT going on that would help. The cost cutting guns have turned from wholesale price controls and random no payment schemes to looking to improve care, even if costs will rise in the short term. At 2 trillion dollars a year, the good people paying for healthcare services have an interest and a right to expect that what we do is reasonably connected to making the patient better. That said, separating out what is controllable and what is not is not easy — in spite of best efforts, some patients will develop ulcers, some infections and so on. To refuse to pay the extra costs has two problems: (1) determining what are additional costs, and (2) all such cases are not preventable. Maybe, as the commenter suggested, a reduced fee for some of these services would be a fair reimbursement.
While hospitals represent the big dollars here, don’t be surprised if physician services lag far behind. All this, of course, raises the specter that malpractice actions will follow — if Medicare says it was preventable, obviously you (hospital, doctor) were negligent and have to pay out.
One the one hand, accountability is in. On the other hand, there are real tools being developed and coming online that will give physicians a better ability to manage care. In the short term, you can use national guidelines where available, and create your own for many of the conditions that you see repeatedly. You always have the option to deviate for a specific patient, but standardization enables your staff to anticipate what will be needed, cutting down the time it takes to gets things done. Standardization — protocols — serve as a check to make sure that something is missed.