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Tag Archives: CMS

Brinksmanship

I may end up eating my words about this. We’ll see. James Rohack, the current AMA President, made a post at Kevin MD about why patients should care about fixing the pending Medicare payment cuts. Basically his take on the matter was that if the cuts go through, many physicians will stop seeing Medicare patients and that some seniors on Medicare will have difficulty finding medical care. I tend to agree with him. I commented that we should let Congress cut Medicare payments. Stop fighting it. I won’t rehash everything, but suffice it to say that I think we need a crisis in medicine to get things straightened out right now. A Medicare pay cut of 21.2% has been looming over physicians’ heads for several months now. The same pay cut has come up in the past, but, through some last minute “miracle” (otherwise known as brinksmanship), the pay cuts are averted, the deadlines are extended, and the medial societies pat themselves on the back for all of their hard work in averting disaster. Now the stakes just went up. The Senate blocked the latest legislation to extend the deadlines for the pay cut. Pay cuts will take effect on Monday. Physicians now will have to make an important decision. March 17 is the deadline for physicians to decide whether they will continue to participate in the Medicare program. Things are a little more complicated than this, but the basic consequences of the decision are the following: If physicians decide to participate, then they’re stuck with the 21% pay cut. If physicians decide not to participate, then Medicare patients have to pay the physicians’ fees out of pocket — or find another doctor who accepts Medicare. Why don’t all physicians just drop Medicare and then sign back up when the rate cuts go away? Another arcane rule crafted by Medicare – once you decide not to participate, you can’t participate again for a minimum of two years. So do physicians drop low payments and gamble that payments won’t go up in the future? Or do they bite the bullet and continue providing services at even more of a pittance? Our physician organizations need to collectively tell Medicare to go pound sand. Maybe this is what the government wants. Notice how the payroll deductions for Medicare and Medicaid aren’t getting any smaller. But with less people working, the amount of money collected is becoming less and less while the numbers of people needing the services continues to increase. By significantly reducing the number of available providers, perhaps the government wonks believe that they can reduce the amount of money they spend on care. Initially, that may be true. Then what happens? First, a good percentage of about 40 million AARP members, and a significant portion of the rest of the Medicare population, are going to become extremely upset when they can’t find a doctor to take care of them. Then, just based on sheer percentages, every single member of Congress is going to get at least a few phone calls from angry constituents who are no longer able to find medical care. The legislators will go into damage control mode, but it will be too late – because even if Congress raises the pay a week after the opt-out decision deadline, those doctors that opted out still won’t be able to participate in Medicare for another two years. There will be a lot of turnover in Congress in November and that’s something else we need. If a lot of physicians opt out of Medicare, the health care system will turn chaotic. ...

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Reducing Bloodstream Infections

There’s this light on my way to work that is just a royal pain. It’s set up so that you have to wait for the arrow to make a left hand turn. The intersection is busy, especially in the mornings, and the arrow only stays lit for about 13 seconds. So you end up waiting five minutes or more – through several light cycles – to make the turn. OR … you can go straight through the intersection, turn left into McDonald’s parking lot, pull out of the parking lot, come back to the intersection from the other direction, and make a right turn, saving yourself 4 minutes and 30 seconds. Now mind you that drivers who choose the latter route are, in effect, going through a red turn arrow – they’re just taking a bunch of extra steps to make sure that they are complying with all of the traffic laws in the process. You’re probably wondering what a traffic light has to do with bloodstream infections. I’ll get to that later. This month, Consumer Reports published a well-written article about reducing hospital infections, and a lot of the take-home messages are good ones. The Consumer Reports article focuses on blood stream infections – also known as “septicemia“. Consumer Reports compared central line infection data for intensive care units at 926 hospitals in 43 states. Hospitals voluntarily submit such information to the Leapfrog Group, a nonprofit organization based in Washington, D.C. and Consumer Reports obtained the data from Leapfrog. As many people realize, septicemia and sepsis can lead to significant mortality in patients. Approximately 20–35% of patients with severe sepsis and 40–60% of patients with septic shock die within 30 days. Anything that we can do to prevent bloodstream infections will be a net positive for patient care. So it was interesting to read the data Consumer Reports collected regarding central line-related bloodstream infections. In every state, hospitals significantly decreased the number of central line infections that occurred. In fact, many hospitals – several with more than 6,000 central line days – reported ZERO central line-related blood infections. You read that right. ZERO. Zilch. Nada. Absolutely no incidents of central line-related bloodstream infections. The prevention in central line-related infections is credited to a simple five step checklist that was developed by Peter Pronovost, a Johns Hopkins critical care specialist. He felt that public disclosure of infection rates was a powerful motivator for hospitals to reduce the incidence of infections. I agree, to a point, but there is a bigger motivator out there, though. Cold hard cash. Under Section 5001(c) of the Deficit Reduction Act, the Centers for Medicare and Medicaid Services was required to select diagnosis codes that “have a high cost or high volume”, results in higher payment, and “could reasonably be prevented using evidence-based guidelines.” Bloodstream infections related to catheters was chosen as one of these codes and eventually became known as a “never event” – at least alluding to the notion that such infections should “never” happen and making a firm statement that the government would “never” pay for care related to such infections. In law, the concept of incurring liability for the occurrence of an event, regardless of whether that event is within one’s control is called strict liability. Here are come comments I previously made about strict liability in medicine. Faced with public scrutiny and the possibility of being held liable for providing significant amounts of uncompensated care to sepsis patients, hospitals needed to make changes … and they did. So first I’d like to start by congratulating the hospitals in Pennsylvania that made ...

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Highlights from the Health Reform Bill

These highlights were sent to me in an e-mail. I have not read the entire bill. However, I did check some of the highlights against the text of America’s Affordable Health Choices Act of 2009 (H.R. 3200) and they are generally on point, although some of the commentary isn’t entirely accurate. As one example, the Advance Care Planning Consultation in Section 1233 does not permit the government to “order” your end of life care, but only requires that a physician discuss the matter with a patient and denote the patient’s preferences (Section 1233(a)(hhh)(5)(A)(ii). However, the government does plan to establish a “quality reporting initiative” for end of life care that will essentially coerce physicians into doing what the government wants under the threat of being deemed a “low quality provider” if the physician does not comply. If the government states that “quality care” for end of life involves removing life support on patients that show no improvement after 72 hours, any physician that keeps comatose patients on life support longer than 72 hours will get quality “demerits” from the government. The government may then use those demerits to dock the physician’s pay or to post the physician’s name as providing “low quality” end of life care on some web site. Think about a tremendous database of physicians similar to the “HospitalCompare.gov” web site now. Because of Hospital Compare, hospital administrators strive to be at 100% “quality” even though “good” care may sometimes cause excessive costs without benefit, may be more likely to misdiagnoses and wrong treatments (I commented on this issue previously and the link to the actual article on a government website mysteriously went bad), or may even be more likely to contribute to patient deaths. Draw your own conclusions after reading the sections in the bill. Commentary (from unknown source) is contained below. ————– • Page 22: Mandates audits of all employers that self-insure! (Section 142(b)) • Page 29: Admission: your health care will be rationed! • Page 30: A government committee will decide what treatments and benefits you get (and, unlike an insurer, there will be no appeals process) • Page 42: The “Health Choices Commissioner” will decide health benefits for you. You will have no choice. None. • Page 50: All non-US citizens, legal or not, will be provided with free health care services. • Page 58: Every person will be issued a National ID Healthcard. (Section 163(a) – not entirely accurate – potential action, not mandatory) • Page 59: The federal government will have direct, real-time access to all individual bank accounts for electronic funds transfer. (Section 163(a) – not entirely accurate – potential solution, not mandatory) • Page 65: Taxpayers will subsidize all union retiree and community organizer health plans (read: SEIU, UAW and ACORN) • Page 72: All private healthcare plans must conform to government rules to participate in a Healthcare Exchange. • Page 84: All private healthcare plans must participate in the Healthcare Exchange (i.e., total government control of private plans) • Page 91: Government mandates linguistic infrastructure for services; translation: illegal aliens • Page 95: The Government will pay ACORN and Americorps to sign up individuals for Government-run Health Care plan. • Page 102: Those eligible for Medicaid will be automatically enrolled: you have no choice in the matter. (Section 205(b)(3)) • Page 124: No company can sue the government for price-fixing. No “judicial review” is permitted against the government monopoly. Put simply, private insurers will be crushed. (Section 223(f)) • Page 127: The AMA sold doctors out: the government will set wages. (Section 224) • Page 145: An employer MUST ...

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Mind Snap

I’m getting just about fed up with the Medical Marijuana Advocates (AKA “JCAHO”, AKA “TJC”) and this whole bunch of HospitalCompare.gov bullhokey. The chart police at our hospital audited a bunch of charts from the emergency department and I got letters about several “serious offenses.” First, I got in trouble because I couldn’t be credited with giving antibiotics within the 4 hour … no … now make that 6 hour window for a patient with pneumonia. For the moment forget about the fact that this quality indicator may do more harm than good. Forget that most pneumonias are viral and that requiring doctors to give antibiotics for these viral infections, similar to using Raid to kill dandelions, increases bacterial resistance and helps to spread MRSA. But I digress. It wasn’t that the patient didn’t get timely antibiotics. The patient got antibiotics not within just 4 hours, but within 2 hours. By the way, congratulations on your increased chances of acquiring MRSA due to our government agency’s blind directives, sir. It wasn’t that the patient didn’t get appropriate antibiotics. The patient had allergies to several medications (that were from 50 years ago when he was an infant, so he didn’t know what the reactions were), and given his history, we used clindamycin. My serious offense was that CMS supposedly couldn’t tell what medication was ordered. Instead of writing out “clindamycin 300 milligrams piggyback through the intravenous line over 30 minutes,” the order said “clinda 300mg IVPB.” The nurse gave clindamycin 300 milligrams piggyback through the intravenous line over 30 minutes. But it was still considered poor quality care not because the patient didn’t receive his medication … not because the medication wasn’t given in a timely fashion … but because micromanaging government clipboard patrols with apparently little medical background couldn’t figure out what medication was ordered. Fortunately for everyone involved, the ClindaCyanide and the ClindaDrano were on backorder in the pharmacy. Otherwise, the patient could have received some other dangerous medication beginning with “clinda” via his IV. Oh yeah, I forgot, there are no other medications beginning with “clinda” aside from clindamycin. Just another reason why the whole HospitalCompare.org web site should be viewed with a healthy dose of skepticism. The statistics don’t necessarily tell you what they purport to tell you. But that’s not all … I also got dinged because I didn’t do one of the Medical Marijuana Advocates’ “time out” forms before doing a lumbar puncture and before draining an abscess. “Time outs” are required before surgery so that surgeons don’t cut off the wrong appendage or do surgery on the wrong site. There are multiple requirements for a “time out” including preparing proper documentation (because that contributes so much to patient care), reviewing relevant images (if any), readying any necessary equipment, making an unambiguous mark near the procedure site with ink that will still be visible after any skin preparation (doctor’s initials are suggested), and double-checking the site mark before the procedure. I’m not actually sure that these are the requirements, because I tried to look them up on the Medical Marijuana Advocates’ web site, but they keep the requirements hidden. Isn’t it great how an organization that is supposedly advocating for patient safety keeps all of its initiatives hidden from public view? But I digress yet again. In theory, I don’t have any problems with marking the site to be operated on if a patient is going to be put under anesthesia prior to surgery and won’t be able to say “Hey doc, why are you starting to cut on my left leg when the abscess ...

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Why Rationing of Care Won't Work in the US

I recently read an interesting article by Dick Morris called “Death of U.S. Healthcare” posted on The Hill. Morris was a former adviser to Trent Lott and to Bill Clinton. His opinion is that Obama’s health care reform will cause rationing of medical services and he cites several comparisons between the US and Canadian systems. Another article on The Hill cites President Obama’s promise to provide “basic” health care coverage for everyone. I agree that rationing is going to occur, but there’s at least one thing that will prevent some medical services from being rationed. Let’s use one example. Suppose you want to cut the costs of health care by no longer paying for costly medical care that does not provide a long-term benefit. You assign your employees to perform a “study” on costly medical care. The study done by your employees (kind of like a study on the effectiveness of a medication that is funded by the drug company making the medication) determines that patients older than 90 years of age on dialysis do not show a significant improvement in quality or duration of life. You then create a new medical practice “guideline” that says, based on this medical effectiveness study, dialysis will no longer be an included medical benefit for patients more than 90 years of age. What happens? Some families might pay for the bill for future dialysis out of their own pockets. Some families might just let grandpa die a slow death from his renal failure. Most families will just call “911” and the red taxi with the spinning light on top will come to pick grandpa up at his home and take him to the emergency department. At that time, grandpa will receive thousands of dollars in lab tests to document that he really is in renal failure and that he needs dialysis. If dialysis is necessary, grandpa will receive emergent hemodialysis thanks to EMTALA. He might even need a day or two in the hospital to make sure that he is “stabilized.” Then the red taxi with the spinning light on top will bring grandpa home where he will sit a few more days … until he needs dialysis again. One little phone call and the whole process starts all over again. By excluding preventive care that averts an emergency, the government will create a situation in which the same care becomes more expensive. All grandpa’s family has to do is pick up the phone and hit three little numbers and he’ll get dialysis any time of the day or night. The government will get its wish, though, as it will no longer have to pay for dialyzing nonagenarians. The burden of paying for emergent dialysis will shift from the government to the hospitals. You see, EMTALA requires that hospitals provide stabilizing treatment, but it says nothing about who will pay for the stabilizing treatment. Hospitals will be forced to eat the cost of providing care. As more of the costs are passed on to the hospitals, more and more hospitals will close. Then less medical care, and less emergency medical care will be available for everyone. EMTALA and the numbers 9-1-1 are two reasons why healthcare rationing inherent with socialized medicine will never be a viable alternative in the United States. Rationing will cause cost-shifting which will in turn cause hospitals to close their doors.

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How to get rid of C. diff?

According to this Medscape article, trying to get rid of Clostridium difficile spores by using traditional hand sanitizers won’t cut it. C. difficile spores are everywhere, including tables, curtains, lab coats, scrubs, plants and cut flowers, computer keyboards, bedpans, furniture, toilet seats, linens, telephones, stethoscopes, jewelry, diaper pails, fingernails and physician’s neck ties. The spores themselves aren’t harmful, but when they are ingested, they can transform and cause colitis. C. difficile spores are difficult to eradicate because they secrete a sticky substance allowing them to adhere to surfaces which, in turn, makes them difficult to remove. Think of little beads with a honey coating. In the Medscape article none of the cleansing products – even the soaps – removed more than 90% of C. difficile spores. According to this study, C. difficile can be cultured from the stool of 3% of healthy adults and 80% of healthy infants. This MSNBC article shows that C. difficile is present in 40% of grocery meats. According to this commentary, more than a third of patients in a North Carolina study had community-acquired C. difficile infections (i.e. not the hospital’s fault) and more than half of patients with C. difficile recently used antibiotics. And … one of the quality measures forced upon us by CMS and Hospital Compare requires us to use antibiotics on ALL known or suspected cases of pneumonia within 6 hours of the patient’s arrival. These “quality measures” significantly increase antibiotic use without any improvement in mortality or hospital length of stay. At the same time, they increase the likelihood of C. difficile infections. C. difficile is present in up to 40% of the meat we eat. C. difficile is commonly present in the stool of healthy infants and adults. We can’t completely get rid of C. difficile spores no matter how much we wash. And … for the sake of “quality care,” the government forces us to give many patients unnecessary antibiotics that actually increase the chances that a C. difficile infection will occur. But if C. difficile infections occur in a hospitalized patient, the government won’t pay to treat them because the infections are “never events” and should “never” happen. Go figure.

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