Medical Errors and Medicare

According to the NY Times, Medicare is no longer paying to treat preventable medical errors in hospitals. This includes injuries and infections acquired in-hospital.

Now the US may go down as the first country in history and in the world that establishes this level of accountability for outcomes.

Medpundit has weighed in to be skeptical that not paying for things can improve care.
The Antidote has summarized the intent of the initiative and pointed out (in the last sentence) that it has not been studied rigorously.

I am quite certain there will be many more comments.

While I understand the value of increasing medical accountability, there must still be recognition that all outcomes, including hospital-acquired infections, have multifactorial causation. So what about a catheter-related infection in someone whose immune system is suppressed from medication. What if the infection was acquired outside the hospital, but became evident in-hospital? What if the patient didn't follow directions? What about the visitors?

Not to be stupid about it, but there is a reason the doctor gets paid, even if the patient dies. The service is provided but the outcome cannot be guaranteed.

I remember a patient who came in for a "flu shot" because they'd been horribly sick for a week. We made sure nothing else was going on and determined that he was actually recovering from a viral infection, probably not even influenza.

My advice was to go home, do liquids and the occasional cold remedy but he wanted a shot to make him feel betetr. When I explained that no such treatment existed and the only cure was time, he looked me straight in the eye and bald-faced asked for his money back!

Remember this new Medicare rule hasn't even been released yet, so it's too early to know, but I think there is no way of operationalizing it. There are just too many factors to consider and I doubt anyone at Health and Human Services can keep up with an algorithm of more than 5a couple of steps. It just looks like a bone-headed attempt by a bureaucracy desperate to placate consumer groups, who in turn, have unreasonable expectations of what health care can realistically deliver.

There is no rule that intelligent people can't find a way around. For every rule, there is necessarily a countermeasure. The NY Times article included commentary that suggests documentation of the presence or absence of infections at admission will become a priority. If you can prove someone was admitted with an infection, you'll get paid for the admission. This means that all patients will probably get blood and urine cultures on admission. A misguided rule can bankrupt the country in microbiology tests alone.

The other appalling aspect of this rule is that it does not respect the single most important principle of quality data: NEVER use your data punitively. Despite every temptation to do so, the risk is that you may provide an incentive for people to fiddle with or otherwise manipulate their data. Of course, nobody would actually fudge something as important as infection rates or medication errors. However, if someone did, my response would be, "What did you expect?"

Water flows downhill.

With all due respect to Paul Levy at Beth Israel Deaconess Medical Center, who is uncommonly open with performance data, I don't believe any hospital, possibly even BIDMC, will share quality data again if quality data is used so indiscriminately.

This country desperately needs transparency and a well-thought out response to quality incentives. So far, I don't see it. But the rule is scheduled to be published next week, so we'll see.