Medicine

If we screw up then you don’t pay!

By Chris Rangel MD ⋅ August 19, 2007 ⋅  Email this post ⋅  Print this post ⋅ Post a comment

Medicare Won’t Pay for These Medical Complications!

When you take your car in to the mechanic to have the engine worked on and they screw up your transmission, you don’t expect to have to pay for their mistake. This is the logic that the Federal government is using in its new regulations for hospital reimbursement. CMS will no longer reimburse hospitals for the costs of treating eight complications it considers to be completely preventable. The first 3 should be 100% preventable;

1. Objects left in a patient during surgery (about 1500 cases each year out of millions of procedures performed in the US).

2. Blood incompatibility (less than 40 deaths per year out of millions of units of blood transfused).

3. Air embolism: Air getting directly into the blood during procedures creating bubbles that can cause severe organ damage and death.

The other complications though avoidable in theory are very difficult to prevent 100% in practice.

4. Mediastinitis: Infection of the middle part of the chest usually from contamination during surgery. However there are many other causative variables that are not fully under the control of the surgical team to prevent i.e. blood infection from another site that spreads to the mediastinum and post operative wound infection from coughing or respitory distress.

Studies have found several risk factors for mediastinitis including morbid obesity, diabetics on insulin, surgery lasting more than 5 hours, and a post operative stay in the ICU more than 3 days. So the question becomes, are physicians and/or hospitals going to start avoiding chest surgery in patients who are at high risk for mediastinitis? Will this lead to excessive use of peri-operative “prophylactic” antibiotics which will add to the multidrug resistant bacteria problem?

5. Falls: Anyone who cares for an ailing or elderly family member at home knows how hard it is to keep them 100% safe 100% of the time, even if they are bed bound. Most US hospitals have nurse to patient ratios of 1:5 to 1:8 or more and even with such things like bed alarms and call bells some patients (esp. those with dementia) have the bad habit of getting out of bed without telling anyone. I worry that hospitals may start using more physical and chemical restraints (sedatives) to keep at-risk patients in bed and this can lead to other complications.

6. Catheter related urinary tract infections: The longer a catheter remains in the bladder the higher the risk of infection but even with good care 3-10% of catheterized patients get significant numbers of bacteria in the urine each day and 10-25% of these develop symptomatic infections. Though unnecessary and prolonged catheterization should be avoided, there are cases where it’s absolutely needed like patients with urinary outlet obstruction or neurogenic bladder. Without a catheter these patients risk getting a severe infection or kidney failure by not being able to normally empty the bladder. And again I worry that more patients may be given prophylactic antibiotics even though there is no evidence that this prevents catheter related urinary infections in non-surgical patients.

7. Central venus access catheter related blood infections: Here too, the longer the catheter remains in the higher the risk of infection. Good preventative care does have a significant impact on decreasing these infections. However, the catheter should only be changed to a new site if infection is suspected. Regular changing of the catheter over a guide wire increases the infection risk and regular changing of the catheter to a new site increases the risk of complications like bleeding or pneumothorax.

8. Pressure ulcers: This is mostly preventable as well but not 100% preventable or automatically the result of poor care. Patients at high risk for these ulcers (spinal cord injury with paralysis, advanced dementia, frequent incontinence of urine or stool, poor nutrition, or poor circulation) can develop an ulcer extremely easily. This is best exemplified by the sad case of actor Christopher Reeve who died from an infected pressure ulcer despite getting very good care. These days wound care teams roam most hospitals looking for any early skin breakdown or the beginnings of an ulcer.

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Despite what the Federal government thinks, complications # 4-8 are not 100% avoidable. It would make more sense for CMS to establish a maximum number of these types of complications per year per hospital based on the number of these cases one would expect to see using the best preventative measures. Then they can penalize hospitals that exceed the maximum.

Otherwise it’s not improbable that some hospitals and physicians may take steps to avoid having to treat patients who are at high risk for these complications. Never under estimate the law of unintended consequences (or the ability of hospitals like any business to try and save money).