Preventive Healthcare

[xotoxi]

Are you trying to tell us that if a healthy person never goes to the MD he'll die?

I will guarantee 100% that a healthy person who never goes to the doctor will die.

 

[Emma]

Actually, what PC said was quite well worded, she did not imply they did it on purpose, it was a "mistake". They are paid for their mistakes by Medicare, it does not make them want to make mistakes, it makes them care less about their mistakes.

Section 5001(c) of Deficit Reduction Act of 2005 requires the Secretary to identify conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence‑based guidelines.

On July 31, 2008, in the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule, CMS included 10 categories of conditions that were selected for the HAC payment provision. The IPPS FY 2009 Final Rule is available in the Statute/Regulations/Program Instructions section, accessible through the navigation menu at left.

The 10 categories of HACs include:

1. Foreign Object Retained After Surgery

2. Air Embolism

3. Blood Incompatibility

4. Stage III and IV Pressure Ulcers

5. Falls and Trauma

• Fractures
  
• Dislocations
  
• Intracranial Injuries
  
• Crushing Injuries
  
• Burns
  
• Electric Shock

6. Manifestations of Poor Glycemic Control

• Diabetic Ketoacidosis
  
• Nonketotic Hyperosmolar Coma
  
• Hypoglycemic Coma
  
• Secondary Diabetes with Ketoacidosis
  
• Secondary Diabetes with Hyperosmolarity

7. Catheter-Associated Urinary Tract Infection (UTI)

8. Vascular Catheter-Associated Infection

9. Surgical Site Infection Following:


Coronary Artery Bypass Graft (CABG) - Mediastinitis

Bariatric Surgery:

• Laparoscopic Gastric Bypass
  
• Gastroenterostomy
  
• Laparoscopic Gastric Restrictive Surgery
  
  Orthopedic Procedures
  
  
• Spine
  
• Neck
  
• Shoulder
  
• Elbow

10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

• Total Knee Replacement
  
• Hip Replacement

Payment implications will begin October 1, 2008, for these 10 categories of HACs.

Hospital-Acquired Conditions Hospital-Acquired Conditions (Present on Admission Indicator)

The IPPS rule adds conditions, including one NQF never event, to the list of conditions that have been determined to be reasonably preventable through proper care. Beginning last year, as required by the Deficit Reduction Act of 2005 (DRA), CMS began selecting hospital-acquired conditions (HACs) that were determined to be reasonably preventable. If a condition is not present upon admission, but is subsequently acquired during the hospital stay, Medicare will no longer pay the additional cost of the hospitalization. The patient is not responsible for the additional cost. Rather, the hospital is being encouraged to prevent an adverse event and improve the reliability of care it is giving to Medicare patients.



In last year’s final rule, CMS listed eight preventable conditions for which it would not make additional payments. In this year’s proposed rule, CMS identified nine potential categories of conditions, but based on public comments, is finalizing three of these. The new additional conditions in this year’s final rule include:



· Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity

· Certain manifestations of poor control of blood sugar levels

· Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

Nice post. Very thorough.

Is the premise that the Bush Administration instituted these cost-cutting measures?

No. I was responding to the previous poster stating that Medicare pays hospitals for their mistakes and therefore care less about their mistakes.

And are they currently in effect, meaning are hospital requests for payment being declined?

Yes.

And how is it being determined that the various problems are hospital-caused, meaning are the hospitals responsible for notifying the agency?

No, it's through billing. A hospital cannot bill for those HACs. Either Medicare or the patient. If these occur, the hospital eats the cost of everything related to those complications.

And would this be somewhat of a companion piece with this part of the Stimulus Bill:
"WASHINGTON – The Federal Coordinating Council for Comparative Effectiveness Research recommended that the Department of Health and Human Services prioritize certain types of interventions and populations when allocating $400 million in funding for comparative effectiveness research.

The council recommended that HHS target funding on areas such as medical and assistive devices, procedures and surgery, behavioral change, prevention and delivery systems.

The panel identified "priority populations" to target with CER, including racial and ethnic minorities, persons with disabilities or multiple chronic conditions, the elderly and children.

The council also said HHS should invest in data infrastructure and improve ways to disseminate research findings.

HHS Secretary Kathleen Sebelius will use these recommendations – along with additional ones to be issued by the Institute of Medicine – to develop a specific plan for $1.1 billion in CER funding provided by the American Recovery and Reinvestment Act. The research plan must be complete by July 30, 2009."
Federal council recommends comparative effectiveness research priorities | Healthcare Finance News

I don't think so, it doesn't appear to be. But I'd have to read up on that. Thanks.

And, finally, is the point of your post that Dr. Goodman's suggestion for free market recommendations is already in effect?
And you find it efficacious?

It has certainly been effective, as just in our hospital the infection and complication rate (and injuries from falls) from these particular HACs have been reduced dramatically.

What do you mean by Goodman's suggestion? What part of that do you feel applies to this? (sorry, somewhat confused by the question)

The Medicare ultimatum is effective because it hit the hospitals where it hurts --- and where they'd certainly pay attention --- the bottom line. Is that what you mean?

 

[xotoxi]

Post #15, in which you said:
"I don't believe this AT ALL.

17% is far too high. There is not a 17% complication rate for any surgery.

Plus, the 30 day readmission is far less likely to be a "hospital mistake" then it is to be an "expected complication".

You were commenting on the warranty suggestion by Dr. Goodman.

Actually, I didn't even read the first sentence. I just started reading at "17%..." and commented on that.

As for warrantees for surgery, I have never heard of this and don't know any of the proposed specifics, so I can't comment on it one way or another.

Have a good day.

You too.

 

[Emma]

I can't recall what the rules are related to reimbursement for treatment of these complications after discharge. I seem to remember being told by TPTB that they won't. But that doesn't make sense, really. I don't work in home or extended care, so I'm not sure about that. Xotoxi would know, I bet.

 

[Emma]

I was responding to the previous poster stating that Medicare pays hospitals for their mistakes and therefore care less about their mistakes.

Come to think of it, she is correct in one sense. It took this directive from Medicare threatening to withhold payment for hospitals to institute stringent protocols to help prevent HACs. But as someone who's worked as a hospital nurse for over 25 years, I wouldn't go as far as to say they don't care about mistakes. I don't believe that to be true. Especially at the staff level. Even committing the smallest error is agonizing for us. Trust me.

 

[Darkwind]

In reality, preventative care is a good thing. It can and does lead to catching things that can be treated early as opposed to not being able to treat it at a later stage.

Not to mention, that preventative healthcare can alert you to possible dangers down the road and give you information on how to head off those dangers through lifestyle changes.

However, preventative care should be an out of pocket expense or an expense paid from a Health Savings Account.

Health insurnace itself should be for catastrophic care only.

If you are fortunate to have a health plan through an employer that offers prevenative care, one would be a fool to not use it. If you don't look into opening a Health Savings Account that can be directly deposited to through a payroll deduction. It may take a year for you to build up enough of a balance to cover your costs, but once you do, you can do the annual or biannual visits to the doctor and be able to cover those expense.

 

[xotoxi]

I can't recall what the rules are related to reimbursement for treatment of these complications after discharge. I seem to remember being told by TPTB that they won't. But that doesn't make sense, really. I don't work in home or extended care, so I'm not sure about that. Xotoxi would know, I bet.

There are no penalties to a hospital if a patient with CHF is discharged home, and along the way, they decide to stop for a bite to eat at the Chinese buffet, and are subsequently readmitted to the hospital with flash pulmonary edema.

Nor should there be.

 

[PoliticalChic]

Section 5001(c) of Deficit Reduction Act of 2005 requires the Secretary to identify conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence‑based guidelines.

On July 31, 2008, in the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule, CMS included 10 categories of conditions that were selected for the HAC payment provision. The IPPS FY 2009 Final Rule is available in the Statute/Regulations/Program Instructions section, accessible through the navigation menu at left.

The 10 categories of HACs include:

1. Foreign Object Retained After Surgery

2. Air Embolism

3. Blood Incompatibility

4. Stage III and IV Pressure Ulcers

5. Falls and Trauma

• Fractures
  
• Dislocations
  
• Intracranial Injuries
  
• Crushing Injuries
  
• Burns
  
• Electric Shock

6. Manifestations of Poor Glycemic Control

• Diabetic Ketoacidosis
  
• Nonketotic Hyperosmolar Coma
  
• Hypoglycemic Coma
  
• Secondary Diabetes with Ketoacidosis
  
• Secondary Diabetes with Hyperosmolarity

7. Catheter-Associated Urinary Tract Infection (UTI)

8. Vascular Catheter-Associated Infection

9. Surgical Site Infection Following:


Coronary Artery Bypass Graft (CABG) - Mediastinitis

Bariatric Surgery:

• Laparoscopic Gastric Bypass
  
• Gastroenterostomy
  
• Laparoscopic Gastric Restrictive Surgery
  
  Orthopedic Procedures
  
  
• Spine
  
• Neck
  
• Shoulder
  
• Elbow

10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

• Total Knee Replacement
  
• Hip Replacement

Payment implications will begin October 1, 2008, for these 10 categories of HACs.

Hospital-Acquired Conditions Hospital-Acquired Conditions (Present on Admission Indicator)

The IPPS rule adds conditions, including one NQF never event, to the list of conditions that have been determined to be reasonably preventable through proper care. Beginning last year, as required by the Deficit Reduction Act of 2005 (DRA), CMS began selecting hospital-acquired conditions (HACs) that were determined to be reasonably preventable. If a condition is not present upon admission, but is subsequently acquired during the hospital stay, Medicare will no longer pay the additional cost of the hospitalization. The patient is not responsible for the additional cost. Rather, the hospital is being encouraged to prevent an adverse event and improve the reliability of care it is giving to Medicare patients.



In last year’s final rule, CMS listed eight preventable conditions for which it would not make additional payments. In this year’s proposed rule, CMS identified nine potential categories of conditions, but based on public comments, is finalizing three of these. The new additional conditions in this year’s final rule include:



· Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity

· Certain manifestations of poor control of blood sugar levels

· Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

Nice post. Very thorough.

Is the premise that the Bush Administration instituted these cost-cutting measures?

No. I was responding to the previous poster stating that Medicare pays hospitals for their mistakes and therefore care less about their mistakes.

Yes.

No, it's through billing. A hospital cannot bill for those HACs. Either Medicare or the patient. If these occur, the hospital eats the cost of everything related to those complications.

And would this be somewhat of a companion piece with this part of the Stimulus Bill:
"WASHINGTON – The Federal Coordinating Council for Comparative Effectiveness Research recommended that the Department of Health and Human Services prioritize certain types of interventions and populations when allocating $400 million in funding for comparative effectiveness research.

The council recommended that HHS target funding on areas such as medical and assistive devices, procedures and surgery, behavioral change, prevention and delivery systems.

The panel identified "priority populations" to target with CER, including racial and ethnic minorities, persons with disabilities or multiple chronic conditions, the elderly and children.

The council also said HHS should invest in data infrastructure and improve ways to disseminate research findings.

HHS Secretary Kathleen Sebelius will use these recommendations – along with additional ones to be issued by the Institute of Medicine – to develop a specific plan for $1.1 billion in CER funding provided by the American Recovery and Reinvestment Act. The research plan must be complete by July 30, 2009."
Federal council recommends comparative effectiveness research priorities | Healthcare Finance News

I don't think so, it doesn't appear to be. But I'd have to read up on that. Thanks.

And, finally, is the point of your post that Dr. Goodman's suggestion for free market recommendations is already in effect?
And you find it efficacious?

It has certainly been effective, as just in our hospital the infection and complication rate (and injuries from falls) from these particular HACs have been reduced dramatically.

What do you mean by Goodman's suggestion? What part of that do you feel applies to this? (sorry, somewhat confused by the question)

The Medicare ultimatum is effective because it hit the hospitals where it hurts --- and where they'd certainly pay attention --- the bottom line. Is that what you mean?

I meant that, since the patient cannot be charged, is it as though the hospital warranties its services.

I think you answered the question, thanks.

 

[Emma]

And are they currently in effect, meaning are hospital requests for payment being declined?

Yes.

And how is it being determined that the various problems are hospital-caused, meaning are the hospitals responsible for notifying the agency?

Self-reporting, claims, and proper documentation.

If the problems are not documented on admission, and they are present at discharge, the hospital is not paid.

Yeah, I left that out in my response. We are damn careful to do a thorough assessment on admission.

 

[Emma]

I can't recall what the rules are related to reimbursement for treatment of these complications after discharge. I seem to remember being told by TPTB that they won't. But that doesn't make sense, really. I don't work in home or extended care, so I'm not sure about that. Xotoxi would know, I bet.

There are no penalties to a hospital if a patient with CHF is discharged home, and along the way, they decide to stop for a bite to eat at the Chinese buffet, and are subsequently readmitted to the hospital with flash pulmonary edema.

Nor should there be.

What I meant was would Medicare pay for continued treatment after discharge for any of those specific HACs. For example, monitoring INR for someone who developed a DVT after hip surgery, or providing them with lovenox and home care to administer. That sort of thing. We were told that they wouldn't, but that makes no sense to punish the outside provider for a complication caused by poor care within a hospital.