Wednesday, August 22, 2007

Medicare wises up

Medicare is adopting the Pottery Barn Rule for doctors and hospitals: You break it, you bought it. The federal health insurance plan for people 65 and older no longer will reimburse doctors and hospitals for fixing the mistakes they make on patients. Hallelujah.

Medicare will stop paying the costs of treating infections, falls, objects left in surgical patients and other things that happen in hospitals that could have been prevented. The rule change announced this month is among several initiatives that the administration says are intended to improve the accuracy of Medicare's payment for hospital patients who receive acute care and to encourage hospitals to improve the quality of their services. "Medicare payments for inpatient services will be more accurate and better reflect the severity of the patient's condition," Herb Kuhn, the acting deputy commissioner of the federal Centers for Medicare and Medicaid Services, said in a statement.

The rule identifies eight conditions - including three serious types of preventable incidents sometimes called "never events" - that Medicare no longer will pay for. Those conditions are: objects left in a patient during surgery; blood incompatibility; air embolism; falls; mediastinitis, which is an infection after heart surgery; urinary tract infections from using catheters; pressure ulcers, or bed sores; and vascular infections from using catheters.

The Centers for Medicare and Medicaid Services said it also would work to add three more conditions to the list next year. "Our efforts in this arena and in other payment rules are to ensure that CMS is an active puchaser, not passive payer, of health care," Jeff Nelligan, a spokesman for the agency, said Saturday. He said the rule "underscores our drive toward quality, efficiency and integrity in the hospital setting."

Hospitals in the future will be expected to pick up the cost of additional treatment required by a preventable condition acquired in the hospital. "The hospital cannot bill the beneficiary for any charges associated with the hospital-acquired complication," the final rules say.

Congress in 2006 gave the Centers for Medicare and Medicaid Services the power to prevent Medicare from giving hospitals higher payment for the extra costs of treating a patient when infections and other preventable conditions occur during a hospital stay.

Hospitals are to begin reporting secondary diagnoses present on the admission of patients starting with discharges on October 1. Then, starting exactly one year later, cases with these conditions would not be paid at the higher rate unless they were present on admission, the agency said.

Last year, Mark McClellan, then director of the Medicare and Medicaid programs, said the government could save hundreds of millions of dollars a year if the Medicare program stopped paying for medical errors such as operations on the wrong body part or mismatched blood transfusions. Medicare provides coverage for about 43 million elderly and disabled people. The Medicare program's expenses totaled about $408 billion in 2006; costs are expected to rise rapidly in coming years.

Well good for the government. Physicians have raked in plenty over the years from Medicare. They didn't all use to drive Mercedes. And doctors earn the money as most of them put in long hours. But dang, surgeons are paid too much money to leave instruments inside patients.


Long ambulance trips kill people

But the British government plans to make the trips longer

People are more likely to die in emergencies if they have to endure long ambulance journeys to hospital, research suggests. As plans to close some accident and emergency departments and district hospitals in favour of larger but fewer specialist units come under increasing attack, a study finds that patients with breathing difficulties have more chance of dying the longer they stay in the ambulance.

A team from the University of Sheffield traced the results of more than 10,000 life-threatening 999 calls and concluded, in a report in the journal Emergency Medicine, that the longer the distance, the greater the likelihood of death. The risk of death for people who were unconscious, not breathing or suffering chest pain rose by one percentage point for every 6.2 miles (10km) travelled. The researchers said that the findings could affect government plans to reconfigure emergency care into a limited number of specialist centres.

The research, which is published today and is based on data taken between 1997 and 2001, coincides with the launch of a Conservative campaign against the closure of maternity services and A&E units. Promising a "bare- knuckle" fight with the Government, David Cameron, the party leader, said yesterday that people did not understand why these services were being shut down when emergency admissions and births were rising.

Previous research, cited in government reports backing the shift to bigger, specialist emergency units, failed to find any evidence that taking patients further by ambulance had an effect on survival. The new study, by contrast, finds that they do. Those most likely to be affected are patients with severe breathing problems. Their chances of dying were 13 per cent if the distance to hospital was between 6 and 12 miles, but 20 per cent if it was more than 12 miles.

The Sheffield team, led by Professor Jon Nicholl, traced the outcome of calls to four ambulance services. Using the grid references of the call and the hospital to which the patient was taken, they worked out the straight-line distance between the two, and then compared that with the outcome for each patient. The distance to hospital varied from less than one mile to as much as 36 miles. The median was just over three miles. Of the 10,315 patients traced, 644 had died. The results show that deaths increase with distance. Overall, 6.2 per cent of the patients died, but for the shortest journeys - fewer than six miles - the death rate was lower, at 5.8 per cent. For distances between seven and twelve miles, 7.7 per cent died, and for distances of more than 13 miles the figure was 8.8 per cent.

Other factors need to be included in any decision to relocate A&E services. For example, bigger specialised units might make up for the greater distance travelled by offering better care on arrival. Professor Nicholl said: "Decisions regarding reconfiguration of acute services are complex and require consideration of many conflicting factors. Our data suggests that any changes that increase journey distances to hospital for all emergency patients may lead to an increase in mortality for some."


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