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

Tea Acuff tacuff at swbell.net
Fri Oct 5 20:57:45 EDT 2007 

I agree with Mike and Ed. Medical economic systems like all the systems with which we work at the level of cell, organ, organ system, person or patient populations are systems not "static" equilibriums of 10 to the 23rd power which are seen  at population levels. We interact at the individual level. I don't have the math to show it, but any influence from top down aways has a different result from even the same force applied else where. Give cardiolplegia after bypass and see if the same effect happens. It is "absolutely obvious"!

tea


----- Original Message ----
From: Edward Bender <ebender001 at charter.net>
To: OpenHeart-L at lists.hsforum.com
Sent: Friday, October 5, 2007 5:47:00 PM
Subject: Re: [HSF] Why should Health Purchasers pay for the cost of ourcomplications?


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?> >  
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