Taking pay for performance to a ridiculous extreme

This story‘s been floating around the blogosphere for a few days now, and I’ve been wanting to weigh in. Basically, Medicare is saying that it will no longer pay for conditions and treatments that result from hospital errors. Sounds reasonable on the surface, right? After all, if a surgeon leaves a sponge in a patient, why should the patient or the patient’s insurance company have to pay for the extra operation that it takes to remove the object and the additional hospital time? Most surgeons, at least, don’t charge a fee for the reoperation to remove a retained surgical instrument or object, although hospitals still charge for O.R. time and however long the patient is in the hospital.

The problem is, this policy goes far beyond that. It’s how it defines “medical errors” that’s the problem:

In a significant policy change, Bush administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars.

Eileen O’Neill-Pardo’s mother, Margaret, died after an infection developed at a hospital.
Private insurers are considering similar changes, which they said could multiply the savings and benefits for patients.

Under the new rules, to be published next week, Medicare will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.”

Among the conditions that will be affected are bedsores, or pressure ulcers; injuries caused by falls; and infections resulting from the prolonged use of catheters in blood vessels or the bladder.

In addition, Medicare says it will not pay for the treatment of “serious preventable events” like leaving a sponge or other object in a patient during surgery and providing a patient with incompatible blood or blood products.

“If a patient goes into the hospital with pneumonia, we don’t want them to leave with a broken arm,” said Herb B. Kuhn, acting deputy administrator of the Centers for Medicare and Medicaid Services.

The new policy — one of several federal initiatives to improve care purchased by Medicare, at a cost of more than $400 billion a year — is sending ripples through the health industry.

I know what some of you are thinking, particularly those less inclined to like doctors. You’re probably thinking: Greedy doctors! No wonder they oppose something like this. There’s just one problem. Most of the items on the list, although potentially preventable, are not 100% preventable even under ideal conditions. Take pressure ulcers (bedsores), for example. There are certainly nursing care interventions that can greatly decrease the risk of pressure ulcers, but no intervention will reduce that risk to zero. I’ve seen patients where everything was done right, the patients were turned frequently and placed on the latest beds designed to minimize pressure, who still got ulcers. Remember, Christopher Reeve, who presumably got the best skin care available after he became quadriplegic, died from sepsis due to an infected pressure ulcer.

The same is true of catheter-related infections. If a patient has a Foley catheter in place, it’s a path for bacteria to make it to the bladder and cause infection. There are things that can be done to decrease this risk, but there’s nothing that can be done to reduce it to zero–or even close to zero. Infection is a fact of life with indwelling catheters, and the risk increases the longer the catheter is in place. Worse, as the article points out, this initiative could have a paradoxical effect of increasing testing and costs, as hospitals do more diagnostic studies and bloodwork on patients admitted to the hospital to determine whether there is any preexisting infection that only manifested itself during the hospital stay. It’s also not difficult to foresee the increased use of “prophylactic” antibiotics for dubious indications, with the attendant increase in the number of resistant organisms that overuse of antibiotics results in.

Pay-for-performance is not a bad thing in and of itself (although most proposals that I’ve seen provide meager incentives compared to the documentation required), but this proposal is just plain stupid because it’s such a blunt instrument. It would make a lot more sense to set standards for the maximum rates of these particular infectious complications for each hospital based on the mix of patients and the rates that could reasonably be expected if the best evidence-based infection control guidelines are used. Hospitals that exceed that rate by, say, two standard deviations (or even less) would then be penalized in this manner until they got their hospital-acquired infection rates down to an acceptable range. To sweeten the pot, hospitals that exceed these standards by two standard deviations could receive more money for their services. Such a system would make far more sense than this proposal.

Of course, the problem with these regulations is that they are not designed to improve patient care, the justifications of Medicare notwithstanding. That’s just the P.R. In reality, these regulations are primarily intended to save money. That’s their primary purpose. The only thing of which we can be certain in assessing the likely effect of these new regulations is that the law of unintended consequences will be obeyed. For example, in the cause of decreasing falls, it’s not hard to guess that some hospitals may start using more physical restraints or sedatives for demented patients with a tendency to wander. In the case of central venous catheter-related infections, the risk of infection increases with time that the catheter is in place; the only way to reduce it is to remove the catheter and place a new one at a new site. Changing catheters more frequently will (1) cost more money, because it’s a surgical procedure that can be billed for, and (2) potentially expose the patient to more complications, such as bleeding or a collapsed lung, from more frequent catheter placement/replacement. Changing a catheter over a wire is useless for preventing infection, and frequently changing it to a new site has a price, as do the newer antibiotic-impregnated catheters, which also lower infection rates.

There’s no such thing as a free lunch, and cost containment is not a motivation that will necessarily lead to better patient care.

Chris Rangel has more.