Medicare Ups the Ante on Medical Mistakes -- But Risks Going Too Far
Two weeks after health plans like Wellpoint announced they would follow Medicare's lead in refusing to pay for eight preventable medical problems in hospitals, Medicare has upped the ante by proposing nine more conditions for which it won't fully reimburse hospitals, including surgical infections, wild swings in blood glucose and hospital-acquired lung collapse. (Medicare's own press release lists all nine conditions.)
In general, I think this sort of strategy represents a good step toward addressing preventable medical errors that may result in 100,000 or more deaths a year. I've also been inclined to discount doctors' complaints as the entrenched resistance of beleaguered physicians who resent further bureaucratic intrusion into their medical-care decisions. In an ideal world, Medicare edicts such as this one would primarily goad hospitals into devising ways to avoid such problems in the first place.
I've already noted some doctor-blogger complaints about Medicare's decision not to pay for hospital falls, and their concerns that the only way to prevent them entirely would be to restrain most elderly patients -- a drastic solution, not to mention an inhumane one. Now Roy Poses of Health Care Renewal has weighed in with some similar concerns regarding the new guidelines, arguing that many of the problems they address aren't fully preventable even with the best care. Since these are also predominantly issues of older and sicker patients, Poses suggests, hospitals may soon have yet another incentive to deny care to the individuals presumably most in need of it.
Looking specifically at Medicare's proposal to limit reimbursement for episodes of delirium in hospitals -- which, according to Poses' review of the literature, can be reduced but not eliminated by consultation and psychoactive drugs like haloperidol -- he writes:
Is delirium a "never event?" Well, hardly ever...I think Poses raises a good point here, particularly if Medicare has raced well ahead of established evidence and is turning its error-prevention program into yet another attempt to shift costs onto doctors and hospitals. Those kinds of zero-sum games are everywhere in the healthcare system, and are one of the main reasons that medical care costs so much and improves at a glacial pace.Thus, it appears that the surest way to avoid incurring CMS' proposed financial penalty for delirium occurring in the hospital would be to avoid admitting sicker patients who are most likely to become delirious. This, of course, is a perverse incentive that could make care less accessible for those who need it the most, and would violate hospitals' fundamental mission to care for the sick.
Similarly, I would challenge the brainiacs who came up with this proposed rule to show how any of the supposed "never events" could be reliably prevented, short of turning away the sicker patients who are likely to suffer these events.
Still, I can't help but think there's something perverse in the notion that changing any sort of financial incentives is automatically suspect because it will lead doctors to mistreat patients. Taken to extremes, that notion amounts to an argument that doctors should be paid whatever they want, since any limits on their compensation gives them an incentive to cut corners somewhere. While that's undoubtedly true in the larger scheme of things, it's not exactly a useful guide to the hard, real-world issue of deciding where best to spend scarce healthcare dollars.
Poses' argument is also silent on the question of what, exactly, payers like Medicare should be doing -- if anything -- to force hospitals to fix their unacceptably high rates of medical error. If experience to date is any guide, we'll be waiting some time for most medical centers to handle the problem on their own, since there's very little evidence that things have gotten much better since the Institute of Medicine's 1999 report. And that's largely because hospitals haven't tended to face direct consequences for the vast numbers of fatal but preventable mistakes that occur on their watch.
Should we just accept this state of affairs as the cost of modern healthcare? If not, exactly how do doctors like Poses, who is normally quite sympathetic to the need for reform and keenly aware of the perverse incentives that drive healthcare institutions, propose to change things without financial incentives of some sort?
(Photo via Flickr user skycaptaintwo, CC 2.0)