[HSF] Why should Health Purchasers pay for the cost of ourcomplications?

Fri Oct 5 16:00:57 EDT 2007

Occasionally. Trial lawyers argue that they produce better medicine, too.
Cutting off the hands of surgeons make them try harder also. None of these arguments is "free market". Not that the current system is either.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Thursday, October 4, 2007 4:34:49 PM
Subject: RE: [HSF] Why should Health Purchasers pay for the cost of ourcomplications?

Tea:

Insurance will still have the same net effect as CMS refusing to pay extra for hospital acquired infections - those hospitals with higher infection rates will pay higher premiums and therefore still struggle to stay in business.

Michael:

We already do "all the CABGs in insulin dependent morbidly obese COPD, poorly non-compliant" etc types - and so do you and many other centers - and I don't see a problem with that except it means you and your team work much harder. All those patients you put those VADs in, some of which you posted on this forum, are at least 20 times more demanding in perioperative care and complications than the worst obese diabetic poorly compliant CABG you can find. Certainly in my center in New York we have resigned ourselves to the fact that to stay in this business we have no choice than to take on the high risk patients. Our isolated CABG volume this year will be less than 20% of our total volume - if we were to turn down all the complex and high risk cases we would certainly be out of business. I must say that the only way a hospital gets better at treating high risk cases is by doing more and more of them. I have certainly seen our ability to deliver
 'successful' surgical therapy to these patients improve over the last 3 years as we have developed a multidisciplinary team specifically geared towards getting high risk patients through their operation (as opposed to before when success rested primarily on the surgeon and his/her ability). Our approach to the CMS issue has been to devise protocols of minimizing nosocomial infections and not to run away from patients at risk. 

Mind you, the greater problem from a hospital perspective is not treatment of mediastinitis but UTIs, line sepsis, ventilator associated pneumonia and diarrhoea whose loss of reimbursement will cost much more than mediastinitis. I wonder what the fuss is anyway since most of us on the forum (see original thread on antibiotics) -  claim we see infections only once every 500 sternotomies or so, so what is the fuss!

Ani

> Date: Thu, 4 Oct 2007 16:33:01 -0400> From: msfirst at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Why should Health Purchasers pay for the cost of ourcomplications?> CC: > > I think part of the tone of Hal's response is that do you (or your center)> want to do all of the CABGs in the insulin dependent, morbidly obsese, COPD,> poorly non-compliant patients when the local hospitals dont want to> undertake those risk? Do you want to be the center that deals with all of> the DSWI from around town? No matter how great your system is there will> always be a baseline risk of DSWI for which some patients may be a higher> risk - and similar to reporting mortality statistics in the newspaper this> may (is?) another attempt at getting us to think twice about our role as> Doctors.> > > -michael> > > > > On 10/4/07, Ani Anyanwu <anianyanwu at hotmail.com> wrote:> >> > But that is exactly what should happen - hospitals that have high> > complication
 rates or that cannot figure out ways to curtail complications> > and their costs will go out of the business of treating high risk cases.> > They can focus on ambulatory surgery and low-risk inpatient surgery where> > risk of such complications is high. Those hospitals that can figure out ways> > to keep complications down and keep costs down when the complications occur> > will flourish. That is what happens in any other economy.> >> > It is simple. For example if you earn 5000 dollars for each cataract> > operation you do then you keep aside 100$ to cope with complications. If you> > have one infection in 500 and this costs $30,000 to mange then you are fine.> > If on the other hand you have 15 infections then you have a big financial> > problem. Current reimbursement systems allow both of these examples to be> > equally profitable even though one is doing a much worse job. This is how> > all insurance based businesses work - you keep aside some of
 your profit to> > deal with the setbacks.> >> > Say if you are an airline you set aside certain amount to deal with> > compensating passengers for flight cancellations and delays. The onus will> > then be on you to keep this number down to the bare minimum the number of> > cancellations and bumps (by good planning, equipment maintenance,> > efficiency, customer service etc) to maximize profit. You could not argue -> > as physicians do - that the costs of cancellations arising from your> > inefficiency or poor quality should be paid for by the government or> > customer. If you cannot, or refuse to keep the cancellations down, then you> > should not be in the business of selling air transportation - you could for> > instance sell newspapers instead where risks are low.> >> > Hal surprises me when he says he will not take one or two patients because> > of a 2% infection risk (I actually do not believe he would take this stance> > when he thinks about this
 more). All Hal's hospital needs to do is to factor> > the cost of treating these infections in their budget (just like they factor> > unforeseen legal costs for example). Hal is actually a beneficiary of these> > market forces even if unwittingly so. Part of the reason why Hal is very> > busy with high-end complex cases is because he is doing (at high quality and> > low risk) the cases other surgeons cannot do or refuse to do. The same would> > apply if CMS refused to pay for any complications - surgeons and hospitals> > that figured ways of treating high risk cases with low morbidity will> > flourish and others will struggle or perish. The patients will be better of> > because they will be left with fewer hospitals offering services at higher> > quality.> >> > Mind you I am not necessarily giving my opinion here just explaining that> > this makes a lot of sense from the perspective of the health purchaser,> > health policy maker, and the patient.> >> >
 Shoot me....> >> > Ani> >> >> >> >> >> > > Subject: RE: [HSF] Why should Health Purchasers pay for the cost of> > ourcomplications?> Date: Thu, 4 Oct 2007 07:54:20 -0700> From:> > ecdouville at orclinic.com> To: OpenHeart-L at lists.hsforum.com> CC: > > Ani, I> > respectfully disagree. It is one thing to insist on excellent mortality> > statistics; there was the long standing worry about denial of care to high> > risk patients. The shifting of risk to out of state hospitals was one> > documented side effect of this. Once you get in to $100,000 of free care for> > an unavoidable, albeit rare, complication, I believe you then force a> > dialogue between hospital leaders (business folks) and physicians, which> > will unavoidably lead to denial of care to higher risk patients, not as much> > for death, as for complications.> Maybe it is ok, as long as it is someone> > else?> > ________________________________> > From:> > openheart-l-bounces at lists.hsforum.com on
 behalf of Ani Anyanwu> Sent: Wed> > 10/3/2007 5:34 PM> To: openheart-l at lists.hsforum.com> Subject: RE: [HSF]> > Why should Health Purchasers pay for the cost of ourcomplications?> > > > I> > think this issue of Medicare not 'paying' for mediastinitis is being looked> > at the wrong way.> > Medicare is not refusing to pay for a complication per> > se - what is happening is that they are penalizing (fining) hospitals for> > complications that occur. This then provides an incentive for hospitals to> > reduce their complication rates. Similar approaches have been used in the> > British National Health Service with hospitals fined, or subsidies deducted,> > if they did not meet specific Department of Health quality targets.> >> > Hospitals will still get paid for doing the procedure but what it means is> > hospitals with high complication rates will have higher unreimbursed costs.> > There is nothing wrong with this situation per se as it exists in most
 walks> > of life - people who provide less quality service or inferior goods get> > penalized financially and people or products which deliver higher quality> > service cost more to purchase. Health economists will have no problem at all> > with this. Indeed they would wonder why, for example, a hospital with a 5%> > mortality rate, one with a 10% infection rate, one that transfuses 70% of> > patients should all be paid the same for a CABG as one with a 1% mortality,> > 0.5% infection and 10% transfusion rate. The present state of affair where> > there is uniform reimbursement for all manners of delivery of health care is> > scandalous. If you went to buy any other commodity you would not expect to> > pay the same for products of such diverse quality. A car manufacturer could> > not charge 20,000 USD for a car whose brakes failed every other day and> > expect to stay in business, yet we would keep getting paid same for a> > pneumonectomy, and feel we
 are entitled to be paid the same, even if all our> > patients died or developed bronchopleural fistula.> > Of course I know I am> > in the minority but changes like this are inevitable because the present> > system of US healthcare funding and payment, and that of even welfarist> > systems like the United Kingdom, and self-pay systems as in many less> > developed countries, is not sustainable.> > Ani> > > > > From:> > msfirst at gmail.com> Subject: Re: [HSF] post op mediastinitis discussion>> > Date: Wed, 3 Oct 2007 00:18:27 -0400> To: OpenHeart-L at lists.hsforum.com>> > CC: > > This is going to be a disaster. By not willing to pay for a problem,> > > CMS thinks that the problem will go away. We think that these (and > other> > major non-cardiac wound problems) will all end up at major > medical centers> > because the primary surgeons will not take them back > (in part since they> > and their systems will not get paid - and who can > blame them since we do>
 > enough free work). Although, from what I > heard, you can still get paid for> > someone else's problems - which > means all of the major medical centers> > will get all of these patients > - gee, that sounds like a money saving> > plan. Who is going to win > out? Of course the MedMal lawyers - that is a no> > brainer.> On Oct 2, 2007, at 11:47 PM, Douville, Chuck wrote:> > > This> > discussion is relevant to our cardiac surgery colleagues > > around the> > world, although it is a financial issue only in the USA. > > CMS (center for> > medicare services), the agency responsible for > > medicare healthcare> > funding in the US recently announced it would > > no longer pay hospitals> > for costs due to postoperative > > mediastinitis in cardiac surgery patients> > effective within the next > > year. Despite perfect glucose control,> > antibiotic timing etc, my > > own recent morbidly obese re-do AVR pt had his> > chest open 7 hours > > due to difficult
 adhesions. S. epi wound infection on> > day 6 > > required opening his sternum, VAC therapy and IV antibiotics and> > an > > extra week in the hospital. The only way to avoid the infection in >> > > this pt that I can think of is to deny the operation to a 60 yr old > >> > man with critical AS after previous CABG 6 years earlier. I do not > >> > believe the incidence of this problem can ever be zero. Thoughts?> >> > _______________________________________________> > OpenHeart-L mailing list>> > >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To> > UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages> > transmitted by the OpenHeart-L are subject to the > > policies and> >> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> >> > -----------------------------------------> >> > _______________________________________________> OpenHeart-L mailing list>
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