Archive for the ‘CMS’ Category
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?
Posted in CMS, Medicare, Policy | 11 Comments »
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 …
Posted in CMS, Medical Topics, News Commentary | 11 Comments »
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.
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.
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?
Posted in CMS, Medicare, News Commentary | 23 Comments »
Friday, February 26th, 2010
 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. 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.
Unfortunately.
Gutsy move by Congress letting things get this far, though. No matter what happens, this is turning into one helluva game of chicken.
UPDATE FEBRUARY 28, 2010
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.
Posted in Access to Care, CMS, Funding Crisis | 42 Comments »
Monday, February 22nd, 2010
 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 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.
Posted in CMS, Medical Studies, Never Events | 10 Comments »
Monday, August 3rd, 2009
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 auto-enroll employees into the government-run public plan. No alternatives.
• Page 126: Employers MUST pay healthcare bills for part-time employees AND their families.
• Page 149: Any employer with a payroll of $400K or more, who does not offer the public option, pays an 8% tax on payroll (Section 412(c))
• Page 150: Any employer with a payroll of $250K-400K or more, who does not offer the public option, pays a 2 to 6% tax on payroll
• Page 167: Any individual who doesn’t have acceptable healthcare (according to the government) will be taxed 2.5% of income.
• Page 170: Any NON-RESIDENT alien is exempt from individual taxes (Americans will pay for them) (Section 401(a)).
• Page 195: Officers and employees of Government Healthcare Bureaucracy will have access to ALL American financial and personal records.
• Page 203: “The tax imposed under this section shall not be treated as tax.” Yes, it really says that. (Section 441(a))
• Page 239: Bill will reduce physician services for Medicaid. Seniors and the poor most affected. (Section 1121(c))
• Page 241: Doctors: no matter what specialty you have, you’ll all be paid the same (thanks, AMA!)
• Page 253: Government sets value of doctors’ time, their professional judgment, etc.
• Page 265: Government mandates and controls productivity for private healthcare industries.
• Page 268: Government regulates rental and purchase of power-driven wheelchairs.
• Page 272: Cancer patients: welcome to the wonderful world of rationing! (Section 1145)
• Page 280: Hospitals will be penalized for what the government deems preventable re-admissions. (Section 1151(a))
• Page 298: Doctors: if you treat a patient during an initial admission that results in a readmission, you will be penalized by the government.
• Page 317: Doctors: you are now prohibited for owning and investing in healthcare companies!
• Page 318: Prohibition on hospital expansion. Hospitals cannot expand without government approval.
• Page 321: Hospital expansion hinges on “community” input: in other words, yet another payoff for ACORN.
• Page 335: Government mandates establishment of outcome-based measures: i.e., rationing.
• Page 341: Government has authority to disqualify Medicare Advantage Plans, HMOs, etc.
• Page 354: Government will restrict enrollment of SPECIAL NEEDS individuals. (Section 1177)
• Page 379: More bureaucracy: Telehealth Advisory Committee (healthcare by phone).
• Page 425: More bureaucracy: Advance Care Planning Consult: Senior Citizens, assisted suicide, euthanasia? (Section 1233)
• Page 425: Government will instruct and consult regarding living wills, durable powers of attorney, etc. Mandatory. Appears to lock in estate taxes ahead of time.
• Page 425: Government provides approved list of end-of-life resources, guiding you in death.
• Page 427: Government mandates program that orders end-of-life treatment; government dictates how your life ends.
• Page 429: Advance Care Planning Consult will be used to dictate treatment as patient’s health deteriorates. This can include an ORDER for end-of-life plans. An ORDER from the GOVERNMENT.
• Page 430: Government will decide what level of treatments you may have at end-of-life. (Section 1233(b))
• Page 469: Community-based Home Medical Services: more payoffs for ACORN.
• Page 472: Payments to Community-based organizations: more payoffs for ACORN.
• Page 489: Government will cover marriage and family therapy. Government intervenes in your marriage. (Section 1308(a))
• Page 494: Government will cover mental health services: defining, creating and rationing those services.
Posted in CMS, Medical Topics, Medicare, Policy | 42 Comments »
Monday, July 6th, 2009
 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 is on the right leg?” I’ll even go as far to say that the “time out” concept is a good idea under those circumstances.
But apparently the Medical Marijuana Advocates are now applying this “good” idea to areas where it does not belong and are now citing hospitals for compliance issues if there is not a “time out” form on file for every invasive procedure – even those done at the bedside. Of course I can’t find this on the TJC web site either. If this policy is true, it is asinine.
How exactly is it that I’m going to do a wrong site lumbar puncture? It’s not like I’m ruling out meningitis in many jellyfish. I haven’t had to rule out a subarachnoid hemorrhage in a Siamese twin lately. I don’t suffer from short term memory loss, so it’s not like I won’t remember the patient who just signed the consent form for me to do the procedure. Explain to me how drawing a circle and writing my initials on the back of a patient getting a lumbar puncture is going to improve patient safety.
Leg abscesses are just as bad. Good thing JCAHO is saving us from maiming people with abscesses in the emergency department. “Yeah, sir, that 10 cm abscess on your leg disappeared in the three minutes that elapsed between the point when I examined you and the point that I returned to the room after going to get a scalpel. Oh well, as long as you’re here, I guess I’ll just fillet open your thigh to look for ingrown hairs. Ooops! The abscess was on your other leg! Sorr-rry!”
If we’re going to do these forms on every invasive procedure, the lab is going to have a lot more work drawing blood. A spinal tap can be considered “drawing spinal fluid”, so drawing blood must also be an invasive procedure. Now doctors are going to have to be involved with every blood draw.
I’m most worried about a couple of other invasive procedures, though.
Not sure how the female patients are going to explain to their significant others how my initials got on their crotches if I have to do a pelvic exam.
And I could be wrong, but I don’t think that too many guys are going to let me draw a circle around their anus and put my initials there before I get out the glove and lube to do a prostate check.
Well … I’m going to go have a time out, write my initials on my right wrist, get all the proper equipment together (including a bottle and a frosted mug) and have 12 oz of ClindaBudweiser p.o. before I stroke out.
Posted in CMS, Joint Commission, Policy | 20 Comments »
Tuesday, May 26th, 2009
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.
Posted in Access to Care, CMS, Policy | 14 Comments »
Thursday, May 7th, 2009
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.
Posted in CMS, Never Events, Policy | 6 Comments »
Friday, April 3rd, 2009
This NY Times article notes that many patients who become Medicare eligible are finding that the “insurance rug has been pulled out from under them.”
More and more physicians are dropping Medicare and patients can’t find physicians to take care of them.
“The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle.”
There is already a shortage of internists in the US and the ones that are available are unwilling to accept new Medicare patients. Universal coverage doesn’t mean much if no one takes your insurance.
The more I think about this, the more I wonder whether this is exactly what the feds are looking for. They keep taking 15+% out of everyone’s paychecks to fund a Medicare system that fewer and fewer doctors participate in – until everyone pays a lot of money to end up with little or no access to medical care.
Posted in Access to Care, CMS, Medicare | 4 Comments »
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We’re From The Government, We’re Here To Help …
Thursday, August 18th, 2011The 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 …
Posted in CMS, Medical Topics, News Commentary | 11 Comments »