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

Sat Oct 6 03:53:09 EDT 2007

Ed

The argument you present regarding high risk VADs actually does make a lot of sense to me. Indeed that is operational today, for example in Europe such patients would not get a VAD because governments would not fund the high resource use (a form of refusal to pay for the complications), in India such patient would not get a VAD because no self pay patient would spend a million dollars on such an exercise of likely futility. Where I grew up in Africa, such a patient would not even exist because they would long be dead as they would not have experienced the luxury of life prolongation by carvedilol, lisinopril, furosemide, dopamine, milrinone and other such medical wonders that we may take for granted. Even in the USA - many a hospital would not operate on such a patient because they cannot afford to block an ICU bed for weeks and slow down the rest of the service. For a busy coronary bypass center for example you could be talking of an opportunity cost of 50 operations. It would be far more profitable to use that one bed for 50 CABGs than for one million dollar VAD.

If I were a health care purchaser I would certainly extend same to VADs and would not reimburse these high risk futile procedures (same applies to the 85 year olds I see having pneumonectomies for metastatic cancer, thoracoabdominal aneurysms and other such surgical wonders in the US health system). Any patient who wants that 5% chance should fund it through other means (maybe pay extra insurance premiums if you want to live for ever at all costs). Sadly or maybe fortunately I am not a healthcare purchaser but a surgeon. As a surgeon I work for the community and will only do what society chooses to pay for (in my case VADs). I am not society's gatekeeper - society will gate keep for society. I will never however ever justify what I do as correct - in this world it is hard to rationalize billions spent on healthcare futility (including Ed - several of the patients you operate on every year) when millions die in Africa of no clean water or infections treatable by $10 of medication. Yes they should stop paying for million dollar VADs and it wont bother me in the least -  indeed I will fully support it, just as it wont bother me if they stop paying for aortic valve surgery, CABG or anything else I do - I will find other stuff to do. Like when Tea found himself in Nicaragua he certainly was not doing OPCABs.

The arguments I make and the one you suggest do make sense and I would say the world is utopian and it is only economic arguments that rule. Money rules - anyone who suggests otherwise please tell me why only US surgeons are involved in this debate? The only reason why this debate is going on and why this issue arises is because money is running out...

Ani

> From: ebender001 at charter.net> Subject: Re: [HSF] Why should Health Purchasers pay for the cost of ourcomplications?> Date: Fri, 5 Oct 2007 17:47:00 -0500> To: OpenHeart-L at lists.hsforum.com> CC: > > Perhaps the same sort of negative incentives might be of value in the > VAD Business (that's Business with a capital B). Let's say that you > place a lot of VADS in very ill patients. Assume that a significant > number of these patients have a very long and expensive hospital > stay, culminating in death with a million dollar plus hospital bill. > Perhaps you should not be reimbursed for the services to that > patient. Maybe then and only then would you either stop doing these > high risk VADs (in favor of lower risk cases or ambulatory surgery) > or maybe you would try harder to prevent the death of the patient.> > This argument, like the arguments you state below, make no sense > except if you live in a utopian kind of economic world where the only > variables that exist are the ones that you can control.> > Ed Bender, MD> > > On Oct 4, 2007, at 2:14 PM, Ani Anyanwu 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> > 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> > >> -----------------------------------------> > >> _________________________________________________________________> > >> Get free emoticon packs and customisation from Windows Live.> > >> http:// > >> www.pimpmylive.co.uk_______________________________________________> > >> 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> -----------------------------------------> >> > _________________________________________________________________> > 100’s of Music vouchers to be won with MSN Music> > https:// > > www.musicmashup.co.uk_______________________________________________> > 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> > 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> -----------------------------------------
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