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CMS Offering Us Some Rope

Our beloved government is now seeking comments on how it can deny payments to hospitals through patient assessment of the emergency department experience.

According to this entry in the Federal Register, the “Consumer Assessment of Healthcare Providers and Systems” (“CAHPS” for short) doesn’t address patients’ experiences with emergency department services. So the Centers for Medicare and Medicaid Services (“CMS”) is seeking “a rigorous, well-designed emergency department survey will allow us to understand patients’ perspectives on their experiences in emergency departments and how such experiences change over time” … and that will allow them to deny or reduce payments to emergency departments that don’t comply with its arbitrary and irrational standards.

In other words, CMS is saying “Here’s a bunch of rope. See if you can form a knot that will form a big loop at one end and that will support the weight of an average human.”

And I’m going to snap if I hear one more person say that “we need a seat at the table or the decisions will be made for us.”

Newsflash: We’re not invited to be “at” the table, we’re what’s on the menu. They aren’t doing this to make medical care “better.” They’re doing this to find a way to justify cutting payments further.

You want to see your emergency medical care funding dry up because you had to wait too long or because you didn’t get your Dilaudid shot soon enough, that’s your business. As more and more hospitals close because the government pays them less due to your bad scores, you are essentially rationing your own care.

I’ve had people argue that emergency departments need to be evaluated and regulated.
Stop for a minute and think about why you go to the emergency department. Do you go there just to be seen quickly? Do you go there just to get pain medication? Do you go there just so that people will respect your privacy? Do you go there so that people will listen to your complaints? If that’s all you’re rating, the medical system will adapt to meet solely those expectations. Look at how businesses are adapting to cope with the Affordable Care Act’s new requirements. If ratings are based solely on non-quality measures, you’ll get someone that sees you right away, gives you a pain shot quickly, makes sure that your gown covers you, holds your hand for a minute, maybe gives you a prescription for an antibiotic or two, and discharges you to some other doctor to find out what’s causing your problem. And you’ll pay more money for it because the hospital will need to make up its losses on those who pay for their care.

Therein lies the problem. If surveys de-emphasize quality care, then hospitals will de-emphasize quality care. Think I’m wrong? Watch what happens when government pays hospitals based on capitation.  Remember the old HMO days? They’ll return with a vengeance. With decreasing reimbursements, there won’t be any way not to decrease the quality of care. Remember the engineer’s triangle?

When the government comes up with a “Consumer Assessment of Government Providers and Systems” that allows us to pay taxes based upon how satisfied we are with our government providers, I’ll listen. Can anyone come up with any reasons why such a rating system will never happen?
Now apply those same reasons to the hospital and emergency department rating system proposed by CMS.

More patients, fewer hospitals, government mandated “insurance” that pays less than the cost of care, and more ways to cut payments to providers. What could go wrong?

Boy am I glad I’m a doctor.


  1. Is there any debate at all on whether your system of private hospitals earning money of peoples illness is the right thing for the future? The United States spend the highest amount of money on healthcare per capita in the world, but do you have the healthiest population? I´m guessing this is a debate that’s well known for you guys, but for me (a medical student in my last semester in Sweden) it just seem insane.

    Why not look at other systems with a more effective care, like the Swedish for instance. Is government-owned hospitals really such a far fetched idea?

  2. Except for the military and VA (for ex-military), we really don’t have any Government owned medical facilities in the US

    I believe that most of the US Hospitals are not “for-profit” institutions either. They are nominally “not-for-profit” institutions. It doesn’t seem to restrict the amount of money the administrators make, but that is another issue.

    If we were to try and switch to a public/private mix, like is available in some countries, we would basically be starting from scratch. Either the Government would be forced to cough up the money to buy many of the hospitals, or build new hospitals in direct competition with the existing ones.

    It would probably greatly expand the size of the Public Health Service to administrate it.

  3. What outcomes would be better measurements instead?

    • You suggest that “outcomes” may be indicitave of quality. If a surgeon tries to save a critically ill patient and the patient dies, then is the surgeon not a “quality” surgeon?
      That’s just the point. There’s no way to reliably measure “quality” in any venture.
      It’s like trying to say that leather seats and good gas mileage are good metrics for a “quality” car or balanced budget and 90% happy constituents for a “quality” government.
      If we suddenly made good outcomes a substitute for “quality,” then it would create an incentive for doctors to avoid treating severely ill patients for fear of being labeled as providing poor “quality” care when patients died.
      By making all the suggestions about what metrics we *think* measure quality, we invite the government to focus on those metrics only while “quality” continues to decline.
      Then we get what we ask for and have to live with our decisions while the government cuts payments to those who don’t perform well on these irrelevant metrics.

      • If people have negative health outcomes, is that indicative something needs to change? I know that I want positive health outcomes and I would expect both doctors and patients would as well. If a surgeon tries to save a critically ill patient, the outcome should account for the fact that the patient had a certain percentage of likelihood of certain outcomes and evaluate how the surgeon’s actions increase or decrease the likelihood of those positive/negative outcomes. So there is a measurable difference.

      • Everyone wants positive outcomes, but a fact of life is that everyone also dies. So when there is a bad outcome, is there a doctor to blame in every instance? If not, how do you differentiate? The government certainly isn’t going to engage in an in-depth inquiry into every patient death.
        You *believe* that there is a measurable difference for sicker patients, but try to quantify it. Some people may say “measure the APACHE II scores of patients” but I have never seen “quality” indicators that take APACHE scores into consideration.

        CMS wants to use “speed” as a quality indicator. Do you think that fast docs have higher quality than slow ones? Or do faster docs blow off complaints, fail to take adequate history, perform cursory exams, and miss pertinent clinical findings? If you don’t know how medicine works behind the curtain and you only look at the “quality” indicators without knowing what those indicators represent, you’re going to be misinformed … at best.

  4. Whitecoat: by posting this, were you looking for responses or suggestions for the Federal Register’s survey design? Were you looking suggestions for items for the survey? Are you looking for how the patient makes decisions on going to EDs or elsewhere?

    • Not necessarily soliciting comments, but throwing out the concept that I believe we will only create further problems and more barriers to care by engaging in this “quality” rating process. See above.
      When I make these comments, though, I like hearing feedback and engaging in the discussions, so if you disagree, I’d enjoy having a rational discussion about our differences in opinion.

  5. It is easy to say “its all subjective” but we do objectively assess.

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