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View Diary: Medicare: What can we do about it? (314 comments)

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  •  I have to take issue with some (2+ / 0-)
    Recommended by:
    DemFromCT, denise b

    of the proposed ways to cut costs, including one you mentioned in your article: not paying for re-admissions to the hospital. And the so-called "never events."

    One of the biggest problems with Medicare is its rigidity and focus on numbers without looking at the bigger pictures involved. It's part of the issue raised above in the comment by maracucho, where Medicare will pay for useless treatments if the codes match, etc. etc.

    The flip side of this is the policy by which Medicare won't pay for readmissions to the hospital within a thirty day period. That is just utterly ridiculous on so very, very many reasons. Examples: the patient with end-stage heart failure who goes home and goes back to eating salty foods and stops taking diuretics because he doesn't want to go to the bathroom all the time. The patient with lymphedema who gets recurrent cellulitis that is unresponsive to outpatient antibiotics (and Medicare, remember, doesn't pay for home IV therapy.) The mildly cognitively impaired patient who forgets their meds. The patient who won't let the home nurse come in because they don't trust them (has happened in my experience more than once.)

    The onus for these problems then falls on the providers who, in a fractured system where very, very few primary providers see their own patients in the hospital (the job I'm in is now specifically prohibiting the primary care providers from following their own inpatients.) There was a recent study that showed that, indeed, hospital care was less expensive when provided by hospitalists, but total care was more expensive because of problems with coordination of care after discharge. Overall care was less expensive when provided by a primary provider who saw the patient in the hospital. Of course, there are those critics of that study who then want to put all the blame on the primary provider.

    And you wonder why people don't want to go into primary care.

    Similarly with the other "never events." Medicare will never pay for a UTI acquired when a patient is in the hospital. Not only has this led to expensive testing of all patients for the possibility of UTIs on admission, we cannot prevent all UTIs. There are strategies to reduce UTIs but not to absolutely prevent them. Similarly with falls, where studies have not shown any effective strategies to reduce the risk of falls. But since Medicare also prevents the use of restraints, we put ineffective monitors on (great, since there are not enough nurses or aides to get to the patients in time if the monitors go off) or use sitters - again adding to the costs. Damned if you do, damned if you don't.

    And don't even get me started on pay for performance. There is no metric for performance on complicated management of multiple disease processes; the strategies are all just about separating conditions into silos.

    And then there are things that are just ridiculous. For example: statistically, people with COPD who go on oxygen will live an average of 3 years after beginning oxygen therapy. So, Medicare will pay for oxygen therapy for up to 3 years.

    Let that one sink in for a sec.

    Here's the dirty secret about CMS: they don't hire people with boots on the ground clinical experience who recognize the complexity of actually dealing with these issues. They hire number crunchers of various stripes, although you do wonder how much knowledge some of them have with number crunching based on the last example above.

    End of rant. For now.

    Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

    by stitchmd on Sun Aug 21, 2011 at 03:43:35 PM PDT

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    •  I fight much of that (0+ / 0-)

      in my day job, but there's a lot of good in it, including learning about best practices that do work.

      "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

      by Greg Dworkin on Sun Aug 21, 2011 at 03:59:05 PM PDT

      [ Parent ]

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