Archive for the ‘CMS’ Category

BMI Measurements Inaccurate But Still A Government Gold Standard

Saturday, June 14th, 2014


Everyone needs to read this NY Times article and then think about how inane the concept has become.

The Body Mass Index or “BMI” is used as a measure of a person’s body weight. If your BMI is between 18.5 and 25, you’re normal. More than 25 and you’re overweight. More than 30 and you’re obese. The measurement is based on a person’s weight and height, but it was originally created in the 1800s to measure human growth – not as a measure of a person’s ideal body weight or health. More recent studies show that people considered “overweight” using the BMI measurement are healthier than those who are at the lower end of the “normal” measurement. One study shows that likelihood of death increases with a BMI of less than 23. BMI doesn’t account for the distribution of body fat (abdominal fat is less healthy), BMI falsely classifies muscular individuals as “obese”, and even the CDC has recommended that doctors not use BMI as a diagnostic tool.
Yet what is one of the things our government requires that doctors calculate on every patient’s chart in order to meet “meaningful use” criteria?
You guessed it.
A BMI measurement.

This is what happens when inmates run the asylum.

The reason that we are being required to measure BMI isn’t because a patient’s BMI has any meaningful clinical use … it’s that the BMI can be measured. If it can be measured, it can be tracked. If it can be tracked, then people (essentially health care providers) can be manipulated and penalized if some arbitrary number on a meaningless scale isn’t reached.

Think about it. If we tried to find other substitutes for “health”, they would be difficult to calculate. How many calories does a patient eat? How much alcohol does a patient drink in a day or week? How much exercise does a patient get each day or week? There’s no standard way to objectively quantify or objectively measure any of those criteria.

Instead the government sticks with something easy to measure – even though it has no bearing on a patient’s health. With a little propaganda, the government can make all the patients who don’t know any better think that BMI really is a useful measure of health. Then, if the BMI isn’t calculated and put on the patient’s chart, it gives the government a means to reduce or deny payments to the healthcare providers.

Calculating a BMI and asserting that it is a representation of health is like measuring the number of clouds in the sky at 3PM each day and claiming that a higher number of clouds is an accurate representation of good government.

The scary thing is that another industry has been making similar assertions for years and certain village idiots just continue to believe the misinformation.

Patient satisfaction scores have long been asserted to be a surrogate measure for healthcare quality. Of course, those assertions are made by corporations which receive hundreds of millions of dollars each year from hospitals so that they can compare one hospital to another … on a statistically invalid and entirely misapplied metric. Studies prove that higher satisfaction is associated with higher healthcare costs and almost double the amount of patient deaths. Recall the story about the Texas neurosurgeon who maimed and killed patients yet who had great Healthgrades.com scores (which were suddenly removed by the Healthgrades staff when the story broke). Healthgrades knows its data are inaccurate, but persists in collecting and disseminating inaccurate and potentially dangerous information.
Junior high statistics classes teach twelve year olds that inadequate sample sizes automatically prevent you from making valid conclusions from the results. Want a real life example? Open up a pack of skittles, take out 5 pieces of candy, note the proportion of colors, and then see if those proportions match the proportions of colors left inside the pack.

Despite the woefully inadequate sample sizes and scientific evidence showing that these measures have no bearing on patient outcomes, the same government that relies upon BMI measurements as a representation of health is going to rely upon patient satisfaction scores as a measure of healthcare quality … and will reimburse hospitals less for care when they have lower satisfaction scores. Hospital administrators and hospital governing boards swallow this obviously inaccurate and misleading information like high school kids sucking beer through a beer bong — all in the name of profits with little regard to the adverse effects on patient health.

It is refreshing to see that hospitals are starting to be held accountable for these decisions. It is easy to prove administrative negligence and hospital board liability when bad faith actions harm patients so that hospitals can earn more money.

After all … the sun is shining. That means that BMI measurements and payment for satisfaction are bad government policies that no one should follow.

I’m a scientist. I know these things.

CMS One Way Data Transparency

Thursday, January 23rd, 2014

1-23-2014 8-42-19 PMAccording to an article on the CMS Blog, in 60 days the government plans to begin disclosing information regarding payments it has made to individual physicians. In order to receive the information, there has to be a FOIA request and each request will be evaluated on a “case by case basis” which means it is unlikely that they plan to just give their entire payment database over to the first person who makes an inquiry. However, the CMS blog states that the government is planning to publicly disseminate aggregate information regarding payment information.

The AMA, all of the State Medical Societies, and a few dozen specialty societies all oppose the idea (.pdf file), alleging that privacy rights of the physicians would be violated, that releasing raw data would result in “inaccurate and misleading information,” and that releasing information such as a physician’s National Provider Identifier would subject the physicians to identity fraud.
On the other hand, watchdog groups such as the “Council for Affordable Health Coverage” believe that all of the data regarding physician payments should be on a publicly accessible database rather than being disseminated on a case-by-case basis.

CMS responded to the medical establishment’s concerns by stating that before releasing individual data, it will consider the “importance of protecting physicians’ privacy and ensuring the accuracy of any data released as well as appropriate protections to limit potential misuse of the information.”

To me, this should be a no-brainer. If any entity does business with the government – not just physicians – disclosure of what services are being performed and what payments are being made should be a right to every citizen.  Remember that whole bit about establishing a constitution on behalf of “We the People”? Remember Abraham Lincoln’s dream of a government of the people, by the people, and for the people? People are the government. If We the People are paying for services through taxes then there is always an overwhelming public interest in seeing how much We the People are paying. If those providing services to the government don’t like it, then do business somewhere else.

With very few exceptions, We the People should be able to see a full and detailed accounting of all government income and expenditures – not just aggregate physician payments.

That’s where CMS’ whole “we’re disclosing physician payments to prevent fraud and abuse” argument falls apart.

Payments to individual doctors are going to be disclosed. Also, any payments or “transfers of value” physicians receive from pharmaceutical companies or medical device manufacturers is also on a government database.

What isn’t going to be disclosed?

  • It isn’t clear whether CMS will release payments to physicians per individual procedure or per individual office visit. My guess is that it won’t. So you won’t know whether your doctor works 4 hours a day twice a week or 12 hours a day for seven days a week to get the payments that CMS is disclosing. You won’t know the overhead in the doctor’s office or the amount of the payments on the doctor’s student loans or the thousands of dollars each month that the doctor pays in malpractice premiums. CMS won’t tell you to divide their “payment” by at least one third to account for taxes that the doctor pays. CMS will just provide you with a number so that everyone can shake their heads at how unfair it is that medical providers are being paid so much
  • It also isn’t clear whether CMS will break down payments to hospitals by specific ICD-9 or CPT codes. To be fair, CMS has published aggregate data for payments to hospitals for the top 100 DRGs, but those payments are several years out of date, in the aggregate, and only involve “average covered charges” and “average total payments” but do not itemize what CMS pays the hospitals for specific services. The aggregate payments include intangible variables such as “teaching,  disproportionate share, capital, and outlier payments” so it is impossible to compare “apples with apples” using the data.
  • And CMS definitely won’t divulge information about patients. The Federal Register Notice (.pdf file) signed by CMS administrator Marilyn Tavenner and approved by Kathleen Sebelius, the Secretary of the Department of Health and Human Services specifically states that “in all cases, we are committed to protecting the privacy of Medicare beneficiaries.” Those superusers and drug seekers who run up the health care tab on the public dime are protected from scrutiny.

On one hand, CMS alleges that it wants to create transparency to avoid fraud, but on the other hand it releases only select data.

Where is the data on how often CMS has denied payments to physicians or to healthcare organizations for services that were provided?
Where is the data showing why those payments were denied?
Where is the data showing how often the denials were reversed and how much extra time that CMS was able to avoid paying for legitimate services by inappropriately denying payments?
Where is the data on the average length of a phone call it takes to contact CMS regarding an inappropriate denial?
The fact is that we don’t get the “transparency” when we look back at CMS.
It’s a one-way mirror.

If we’re really interested in combating fraud, why can’t we get FOIA requests for aggregate payments made on behalf of patients? We don’t need to know what the payments are for and public agencies delivering social security or welfare benefits are not covered by HIPAA privacy rules, so don’t even go there.
Shouldn’t it be my right to see how much of my tax dollars are being paid to the guy on disability down the road with the souped-up Escalade who goes on vacation more than I do and who is out on the golf course all day? Or is it that fraud only of “public interest” when it is committed by medical providers?

CMS is taking this approach for one reason – to vilify medical providers.

With 37% unemployment in this country, medical providers are an easy target. Publish data that inflame a large proportion of the population, allege that medical providers are being “greedy” for not accepting pay cuts, then use that negative public opinion as a means to justify cutting payments and creating even more laws and regulations that make the practice of medicine even less appealing. When you’ve driven enough providers out of health care so that there isn’t sufficient access to all the aging baby boomers and newly-minted Medicaid patients, you can blame that on the medical providers, too. How dare we not provide care to our fellow citizens.

I’m all for transparency, but there needs to be global transparency, not a bunch of smoke and mirrors labeled as “transparency” and used as a means to an end.
You want to publish the data? Publish all of the data.

Come to think of it, maybe we can create public databases of all the payments and perks to all government officials. How much in “transfer of value” has Kathleen Sebelius received since she entered office? Business trips? Meals? Office supplies? Travel?

Betcha those numbers would put payments provided to most medical providers to shame.

More Joys of Electronic Medical Records

Tuesday, January 22nd, 2013

HistoryGo up to your favorite emergency department staff member and ask them what they think of “twofers.”

Depending on that person’s mood, chances are that you’ll get anything from a scowl to a punch in the gut in response. Two patients from the same family both needing emergent medical care at the exact same time? It still happens … car accidents, fires, maybe a stomach bug. But it can be frustrating. There’s a saying in emergency medicine that the likelihood of a true emergency is inversely proportional to the number of patients in the family registering to be seen.

That being said, a “fivefer” will raise the hairs on the back of the neck of pretty much any emergency department personnel. When the complaint is that everyone in the family has a cough, three of the five family members smoke, and none of them got their flu shots … well … you get the picture.

One of the frustrations with scenarios like this is the charting involved. The nurse and the doctor are literally stuck at the computer for 30 minutes each, both entering useless information about different patients over and over again – instead of taking care of other patients. The medical records won’t let you proceed without entering the information.
Is there a fall risk?
Is there a risk for tuberculosis?
Does the patient smoke? Nurses have to enter this information even on infants to satisfy government regulations.
Is there a risk of danger in the home?
Is there evidence of abuse?
When entering an order for IV fluid, if the patient has a sulfa allergy, doctors have to acknowledge that there is some potential interaction between saline and the patient’s allergy and describe why we would dare to give salt water to a patient with an allergy to sulfa.
And on and on and on.

So I tried something that sounded easy when I thought of it, but was technically quite difficult when I tried to actually do it. I tried to log the number of times I clicked on different check boxes and the number of different screens I had to navigate in order to document on and discharge/admit a patient.
This is easier said than done.

I never realized how quickly I am able to navigate a byzantine array of computer screens. After clicking on one button to order a medication, I found myself subconsciously moving the mouse to the area of the screen where the next “OK” button would pop up. I had to literally slow myself down to count the clicks and the screens. I’m sure I missed a few in the process.
The number of data points in each aspect of a patient’s history is quite large. There are 144 data potential points to click on just for a patient’s physical exam. The screen to the right is what must be navigated for each and every patient’s history. Each line in the white fields is a data point that must potentially be either right- or left-clicked depending on whether it is positive or negative. I didn’t even bother counting up how many potential data points could be clicked upon, but it numbers in the several hundreds – depending on the presenting complaint.

So I set out to log the clicks and screens. The first few times I tried, I wasn’t able to do it. Finally, when it wasn’t so busy, I made a conscious effort to stop on every screen and mark down clicks and screens. I use some basic templates, so the amount of clicking that I do is actually less than someone who doesn’t use templates.


CMS Offering Us Some Rope

Sunday, December 9th, 2012

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.

Choosing Wisely – Good Medical Practice or Prelude to Rationing?

Saturday, September 8th, 2012

EP Monthly has an important Pro-Con debate between ACEP President David Seaberg and EP Monthly founder Mark Plaster about the “Choosing Wisely” program.

Choosing Wisely is being pushed by the ABIM Foundation as a way to get specialty societies to label certain tests as “unnecessary” or of questionable benefit.

I side with Dr. Seaberg in this argument.

I disagree with the concept some people advance that we need to essentially “do it to ourselves before someone else does it to us” (see the comment to Dr. Seaberg’s position). Reasoning like this is how physicians and patients have lost much of the control of the house of medicine. Read through the news and look at the emphasis on reducing the amount of “unnecessary” care. Just last week, the Washington Times published an article about how the Institute of Medicine stated that we waste $750 billion each year in health care. How could anyone disagree with reducing that which is “unnecessary”? It’s a great sound bite. But as Dr. Plaster notes in his article, the devil is in the details.

How do we define “unnecessary”? A pregnancy test in a male patient is “unnecessary.” No way to justify its use. But other tests which seem to have little clinical utility may be deemed “necessary” for non-clinical reasons. A CT scan may only infrequently show the etiology of a patient’s syncope, but some doctors may believe the CT scans are “necessary” to avoid accusations of improperly evaluating a patient or to prevent being sued for missing a rare neurologic cause of a patient’s syncope. If we want to decrease the amount of “unnecessary” testing, we need to address all of the reasons that such testing is performed. Why doesn’t Choosing Wisely change the preamble of its campaign to include: “The following tests are medically unnecessary and no type of professional or legal liability should ever be imposed upon physicians for failing to order or perform them …”?

I question whether the ties that several ABIM foundation trustees have to the Obama administration (hat tip to A Line of Sight) will affect the mission of this project.

Finally, many of the groups listing “unnecessary” testing in the Choosing Wisely campaign are making their directives at other specialties. Radiologists are telling emergency physicians not to order so many CT scans. Neurologists are telling emergency physicians not to order CT scans for migraine headaches. Unless those specialists are going to come to the emergency department, evaluate the patients, and follow their own recommendations, they have no business telling other specialties what to do. Easy to point fingers when you have no skin in the game.

We need to reduce the amount of testing performed in this country, but I still think that the best way to do so is through deregulation and free market principles. If patients want to pay for a test with little clinical validity, they should be able to do so. They should be able to have the test done ten times if they want to pay for it.
Patients should be able to make an educated decision as to whether they want a have a test performed. And physicians should function as advisers to the patients in this regard, not gatekeepers who deny testing.

In this respect, I predict that Choosing Wisely just won’t work for its intended purpose and it will likely be used as a first step toward rationing care – especially care that ends up with “normal” results.

Certificates of Medical Necessity

Wednesday, January 18th, 2012


Not too long ago I got a letter labeled “URGENT” in my mailbox at work.

The letter was from Walgreens regarding a patient I had seen several weeks earlier. I cut and pasted parts of the letter to make it fit on one page above.

As the prescribing physician, in order for our government to pay for the prescription I wrote for the patient … several weeks ago … I had to sign a statement stating the following:

“I, the undersigned, certify that the above prescribed supplies/equipment are medically necessary for this patient’s well being. In my opinion, the supplies are both reasonable and necessary to the accepted standards of medical practice in the treatment of this patient’s condition and are not prescribed as convenience supplies. By signing this form, I am confirming that the above information is accurate.”

Seriously? To get reimbursement for a medication on the $4 list, the government is forcing health care providers to take the following steps:

A pharmacist has to receive the denial from Medicare, look at the medication, enter all the information into the CMN and generate a letter to me. The pharmacy must then spend 44 cents to mail the letter to me
Once I receive the letter, I don’t remember the patient, so I am then forced to waste time looking up the patient’s chart, reading through it so I could find the diagnosis and make sure that the flipping $4 albuterol prescription wasn’t for the patient’s “convenience.”
The pharmacy then spends another 44 cents for the self addressed postage paid envelope.
Once the pharmacist receives the certificate saying that the patient really does need his albuterol solution, he then has to spend more time going back on the computer, matching the signed statement with the visit and then forwarding the claim onto the government for medication that has already been dispensed.
Then the pharmacy waits months and hopes that it gets back $3 in reimbursement for a $4 medication.

In essence, health care providers waste 50 times as much value in time getting paid for something after the fact than the item is worth. And the government knows it. It is just hoping that one of the providers won’t do all the paperwork so that someone else gets stuck paying for the medication – other than the government. No paperwork, no payment.

Is this what medicine has come to? Harassing providers so much with pre-authorizations and post-authorizations because they don’t have enough to do? What other ways can we concoct to steal services and supplies from medical providers?

Then I thought that since the government uses these authorizations so much, that they must be a good idea.

Before I send in my next tax payment, I’m thinking about sending in a similar authorization to the IRS.

“I, the undersigned, certify that the above tax payments are necessary for this country’s well being. In my opinion, the government purchases made with this money are reasonable and necessary to the accepted standards of accounting practices and are not spent on wasteful or potentially wasteful projects or items. By signing this form, I am confirming that the above information is accurate.”

Any accountants out there? Would this work?

We’re From The Government, We’re Here To Help …

Thursday, August 18th, 2011

The clock is ticking for Parkland Memorial Hospital in Dallas.

Last week, Parkland was cited by the Centers for Medicare & Medicaid Services for several “serious threats” to patient safety. As a result, the hospital is now in jeopardy of losing its ability to participate in the Medicare program unless it submits “correction plans” to CMS by August 20, 2011.

According to a CMS spokesperson, two violations relating to infection control and emergency care issues were “so serious that they triggered ‘immediate jeopardy'” for the hospital. In fact, the reasons for the citation were so heinous that CMS won’t even disclose them to the public until Parkland submits plans on how to fix those super secret problems. That’s the subject of another WTF discussion, but we’ll save that one for later.

The event triggering the CMS investigation involved a schizophrenic psychiatric patient with a heart condition who died while in the emergency department. The report states that the technicians who subdued the man did not have “effective training” and that the patient was not closely monitored before his death.

According to the article and an interview Parkland’s Chief Medical Officer, Parkland was cited for several reasons. Based on what I can gather from the article, two of the hospital’s citations were for:
– Moving patients with less serious symptoms to a separate urgent care center for medical screening
– Staff touching a patient and then touching other surfaces that people would come into contact with

Think about how grave these dangers are.

When a patient is more than 20 weeks pregnant and has abdominal contractions, what happens when she comes to the emergency department? She gets put in a wheelchair and brought directly to the obstetrical department for further evaluation. So by virtue of their presenting complaint, some pregnant women are immediately sent to a different department for medical screening. This process is apparently acceptable for CMS because it happens everywhere in the country.

Suppose the same 20 week pregnant patient has a hangnail instead of being in possible labor. Now, instead of moving the patient to obstetrics for pregnancy evaluation, Parkland was moving the patient to its urgent care department for further medical evaluation.

Both “moves” are made based upon a patient’s presenting symptoms. However, when a patient with one presenting complaint is sent to one area of the hospital for further evaluation, it is entirely acceptable while sending the same patient to a different part of the hospital for a different presenting complaint constitutes a “serious violation” and a “threat to patient safety” that must be stopped immediately.

Makes perfect sense to me.

Then there’s the “let’s have a sterile universe” violation of epic proportions.
Touching a patient and then touching surfaces that other people may contact is a “serious and immediate” health threat? Let’s see this logic. I’m assuming that the government means that it is a serious health threat to potentially transfer germs from one person to another.
What should healthcare providers do in order not to create a “serious and immediate health risk”?
All bathrooms must be completely sterilized between each use. After all, one patient could come into contact with a surface that another patient touched.
Doorknobs to all hospital doors must be sterilized after every person touches them. After all, one patient (or worse … a visitor [gasp]) could come into contact with a surface that another patient touched.
Beds. Walls. Chairs. Everything must be sterile, dammit. Otherwise, we’ll all crumple up and die like those things on War of the Worlds.

Do I think that medical providers need to wash their hands more frequently? Of course.
Could we do a better job at controlling infections all over the world (not just in hospitals)? Sure.
Is there any basis in medical science showing that avoiding contact with surfaces after touching patients will control infections when no other fomites are addressed? Not a shred.
What if a patient touches a surface in a common area directly? What if a patient touches the registration desk? What if a blood pressure cuff is put on the surface after being used on the patient? What if a hospital gown touches the floor after a patient used it? What if the patient was going through the drawers without the medical staff’s knowledge?
Maybe we should just bug bomb every hospital in the US every hour on the hour.
Got, that, Parkland? Put that in your plan of action. Bug bomb the hospital every hour on the hour and have a steady stream of alcohol sanitizer spraying from sprinkler heads. That’s the only way you’re going to keep your Medicare privileges.

I’m sure that CMS has more infection control violations in its own offices than Parkland has in its hospital. You CMS wonks sterilize your computer keyboards much? Door handles? How about your telephones (when you answer them, of course)?

And what is CMS’s official position on presidential candidates shaking hands during election campaigns? I don’ t see the candidates washing their hands between shakes. Nope. Nary even a squirt of alcohol sanitizer. Those germ infested malevolents are engaging in a serious and immediate risk to the health of every prospective voter at these rallies! They’re like giant bumblebees pollinating the population with deadly germs! GACK! Call off the elections!

Unless CMS is holding back on some other huge bombshell about Parkland’s practices, labeling the above triage policy and infection control violations as “serious and immediate threats to patient safety” is alarmist, capricious, and just plain wrong.

And we wonder why health care in this country is in such a wonderful state of affairs right now …

Medicare Cuts Delayed Again — PHEW

Thursday, March 11th, 2010
I had planned to log on and write a quick post reminding docs that they have less than a week to decide whether or not to remain a participating provider in Medicare in the face of 21% payment cuts — and to encourage docs to drop Medicare.

While perusing the morning news, I discovered that once again the Senate has made a last-minute decision to delay the Medicare pay cuts — this time until October 1, 2010. I’ll be linking back to my Brinksmanship article somewhere around September 15, 2010, I’m sure.

According to one Senate Republican, this means that the federal deficit will increase by $100 billion.

Wait. Seven months of foregoing 21.2% cuts to physicians costs the government an extra $100 billion.
That means that 12 months of foregoing cuts would cost $171.4 billion (divide $100 billion by 7, multiply by 12)

Dividing $171 billion by 21.2%, we get a total Medicare payout to physicians every year of $808.6 billion dollars.

Mrs. WhiteCoat gets paid about $70 for an average office visit for a Medicare patient – usually after having to pay her office manager for a couple of hours of time to figure out why Medicare refused to pay the first three times the claim was submitted. Let’s round up. Say Medicare pays $100 for an average doctor visit. Dividing $808.6 billion dollars total physician payments by $100 per doctor visit means that the total number of doctor visits – just for Medicare patients – is a little more than 8 billion per year.

Lets say that there are 50 million Medicare enrollees (these Kaiser numbers are from 2008, so I increased the estimate from 44.8 million to 50 million).

Eight billion visits divided by 50 million patients means that every single Medicare patient is seeing a doctor an average of 161 times per year – more than three times per week every week for the entire year.

Look at it another way. Dividing $808.6 billion by 50 million Medicare patients means that physicians are being paid an average of $16,172 each year for every Medicare patient in the country.

So what are all of us rich doctors complaining about?

How about politicians who are full of hot air.

Where’s the money really going?


Friday, February 26th, 2010

colonel_sandersI 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. Maybe a few of the well-to-do elderly patients will pay out of pocket to continue seeing their current physician. However, most will start calling around to find other physicians who still accept Medicare. The wait lists with those physicians will grow from weeks to months.

In the meantime, elderly patients will go to emergency departments for their health care needs because we emergency physicians will always be there to help them when their doctors aren’t available (I’m already starting to see this happen in my ED) and because the hospitals won’t dare to opt out of Medicare.

Hospitals accept Medicare … Medicare pays for care rendered to seniors … seniors go to hospitals. Seniors who come to the emergency department tend to get BMWs (but remember, folks, defensive medicine doesn’t exist), therefore costs to Medicare go up, not down. Medicare goes bankrupt sooner than anticipated.

A crisis like this is what we need to get legislators back to the table to create a better health care plan. It needs to happen. Even the status quo is unacceptable.

I doubt it will happen, though. CMS has announced that it will not process claims for Medicare payments for the first two weeks of March, so my prediction is that Congress will eliminate the pay cuts next week and that all the physicians will get their “full” payments after March 14. We’ll continue in the same dysfunctional system until the next crisis occurs about 10 months from now.


Gutsy move by Congress letting things get this far, though. No matter what happens, this is turning into one helluva game of chicken.

See Throckmorton’s blog for another good point – with the cuts to reimbursements also come a cut to reimbursements for medical care to all of our soldiers. What happens to Congress?
There are already reports that a bill will be introduced this week to delay the effective dates of the cuts for another 30 days. And the AMA is actually showing doctors how to drop Medicare, if they so choose, including samples of documents to file (.pdf file – also contains excellent explanation of options physicians have regarding participation versus non-participation)
The merry-go-round continues.

Reducing Bloodstream Infections

Monday, February 22nd, 2010

Emperor_Clothes_01There’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 the Consumer Reports list for ZERO central line-related bloodstream infections.
At the top of the list was UPMC Presbyterian – Shadyside. Shadyside was not only tops in the state, it was tops in the NATION. Shadyside had 13,596 patient “central line days” without a single central line-related infection. Amazing.
Also included in Pennsylvania’s list were UPMC St. Margaret in Pittsburgh with 2,902 infection-free central line days, UPMC Magee Women’s Hospital in Pittsburgh with 1,600 infection-free central line days, and Southwest Regional Medical Center in Waynesburg with 1,040 infection-free central line days.

Congratulations to these hospitals on jobs well done.

You’re probably wondering why I chose to look at the hospitals in Pennsylvania, aren’t you?

As part of the public shame er, um, disclosure efforts required under Pennsylvania law, Pennsylvania created a web site to compare various costs of treatment and efficiency of health care for multiple different medical problems. Pennsylvania collects information on more than 4.5 million patient visits each year and then summarizes that information on its Health Care Cost Containment Council web site (which it calls “PHC4″).
It just so happens that one of the metrics on the PHC4 web site is “septicemia” – those same “blood infections” that Consumer Reports wrote about.

Now if all four hospitals dropped their cathether-related blood infections to ZERO, then the incidence of blood infections should also decrease at least a little, right?

Let’s look at UPMC Shadyside. Even though the number of catheter-related blood infections was ZERO, the cases of septicemia increased each year between 2002 and 2008, and they increased a lot. As in 145 cases in 2002 up to 881 cases in 2008. The costs to treat those cases also increased – from $30,000 to more than $69,000 per event. AND their “outlier” numbers for prolonged length of hospital stay in patients with sepsis were worse than expected between 2006 and 2008.

UPMC St. Margaret’s data also showed an upward trend, from 152 cases of septicemia in 2002 to 250 cases of septicemia in 2006 and then down to 209 cases by 2008. Costs also more than doubled during that time period, reaching $37,228 per case by 2008.

Southwest Regional was the only hospital that had a downward trend of septicemia cases, but even that data was haphazard. 32 cases of septicemia in 2002, 40 cases in 2004, 14 cases in 2006, and 23 cases in 2008. The costs for treating septicemia at Southwest Regional also doubled, but in 2008, its charges were $16,253 – less than one quarter of UPMC Shadyside charges for treatment of the same medical problem.

Magee-Women’s Hospital also had strange data. The number of septicemia cases it reported remained between 5 and 9 per year from 2002 to 2005. Suddenly in 2006, the number of cases at Magee-Women’s jumped to 28 and remained between 23 and 28 per year from 2006 to 2008. Its costs increased by almost double from 2004 to 2008, reaching $41,288.

You’re probably thinking that other variables can affect this data, and I’d agree with you. Perhaps more people in Pennsylvania just happened to develop non-catheter related bloodstream infections during those years. Maybe all the other hospitals except for those above are getting contaminated central line kits delivered to them. Maybe some hospitals focus so much on preventing catheter associated bloodstream infections that they drop the ball in other areas. Who knows what other facts may explain the precipitous fall in catheter related bloodstream infections despite a significant increase in bloodstream infections as a whole. It just puts a question in my mind. Are things really getting better or are hospitals all over the country just telling us … and CMS … what we want to hear?

Think about it. For the sake of example, I’m going to use UPMC Shadyside because of their high volume of patients. Assume in 2008, that 10% of the patients with septicemia at UPMC Shadyside were Medicare patients with catheter-related bloodstream infections (this article from Great Britain cites catheter related bloodstream infections as 10%-20% of all hospital acquired infections in the UK, so I’m staying on the low side of the cited statistics). If all those infections were considered “never events,” Shadyside would have lost more than $6 million dollars in 2008 on the care of those patients. Every patient with a catheter-related bloodstream infection at Shadyside can translate into more than $69,000 in lost revenue for the hospital.

With reimbursements being cut and many hospitals bleeding red ink, you think that every hospital out there doesn’t have an incentive to selectively interpret bloodstream infection data?

Here are some examples of how that selective interpretation might occur.

All of the data that I could find relates to catheter associated bloodstream infections in the Intensive Care Unit. If a patient develops signs of an infection and is then moved out of the ICU before official culture results come back, does that patient get dropped as a data source? Don’t know. I couldn’t find any guidelines on what to do in that situation.

How is a “catheter associated bloodstream infection” even defined? There’s no universal definition. Even the CDC admits that “the rate of all catheter-related infections (including local infections and systemic infections) is difficult to determine. Although CRBSI [“catheter related blood stream infections”] is an ideal parameter because it represents the most serious form of catheter-related infection, the rate of such infection depends on how CRBSI is defined.”

We can use the definition from the National Nosocomial Infections Surveillance System requiring “presence of recognized pathogen” in blood cultures not “related to” infection at another site. What if the pathogen was not specified? Perhaps only gram positive cocci but subtyping not performed. Does that data get thrown out? What if the patient has a pimple at another site? Is that “related to” the blood stream infection? Does that data get thrown out? What if there is a bedsore anywhere on the patient’s body? No longer a catheter-related bloodstream infection?

Appendix A of this MMWR report (.pdf download) has other definitions. One definition requires that the same organism be cultured from the blood and the tip of the catheter that has been removed. What if the catheter tip wasn’t cultured? Another definition requires that two blood cultures at different times show the same organism. What if only one blood culture was done?

The definitions don’t say anything about antibiotics, either. If a patient receives antibiotics prior to blood cultures being drawn, it is likely that the antibiotics in the bloodstream will inhibit bacterial growth and will falsely decrease the numbers of positive blood cultures. If the patients get antibiotics through their central lines, how do you think that will affect the results of the cultures of the tips of the central lines? Is that reportable?

Leapfrog Group and the federal government make a big deal about paying for performance. “Tie payment to outcomes” the Leapfrog Group advocates. When you start tying payments to outcomes without a well-thought out plan on how to reliably measure the outcomes, you’re going to get exactly what you pay for. Garbage in, garbage out. Just like  drivers trying to avoid waiting five minutes to turn a corner when they’re late for work, hospitals have an incentive to avoid undesirable situations by taking advantage of loopholes in the rules and definitions.

The thing that bothers me most about data like this is that it tends to make people both complacent and angry.
People become complacent when they go to hospitals with “zero” catheter related bloodstream infections. What a great place this must be! I’m safe here! Maybe that’s true, but maybe it isn’t true. How is their data interpreted?
People become angry when they’re affected by one of these highly-publicized negative outcomes.  Hospitals that still “allow” patients to develop such infections are viewed as negligent and get a bad reputation.

Does this mean that hospitals shouldn’t follow the Dr. Pronovost’s five step checklist? Absolutely not. But if those checklists work sooooo well, then why doesn’t the government just say “we’re not going to pay you if you don’t use the checklist”? Focus on the process, not the outcome. You’ll get everyone following the checklist overnight. Then you’ll see how effective it really is.

Nah. There’s more political capital in making the agencies look good and making the hospitals look bad.

What’s the point of this protracted post? There are a few.
1. You get what you pay for. If you pay for statistics showing a decrease in some measured outcome, you’ll get statistics showing a decrease in some measured outcome.
2. You don’t get what you don’t pay for. When you stop paying for an outcome, those providing the services might find a way to avoid the outcome, they might find a way to make it look like the outcome never happened, they might find a way to make someone else pay for the outcome, or they just might stop providing the services altogether.
3. The devil is in the details.

Now, what’s all this about CMS representatives marching in some parade … with an Emperor?

P.S. Did anyone see any government run hospitals in Consumer Reports’ list? I didn’t.

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