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The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Monday, April 21, 2008

Latest we-won't-pay proposal from CMS-Silly is too weak a word

The latest proposal from CMS to not pay for treatment of certain conditions appears to demonstrate evidence of such an outstanding ignorance of medicine that it is difficult to find words strong enough to characterize them. These conditions are referred to as " hospital acquired conditions" that are "reasonably preventable through the applications of evidence based guidelines" This are beyond absurd. The actions taken by hospitals to live with this rule (if it is finally approved and becomes a rule) will elevate the concept of unintended consequences to new heights.

Here is press release and here you can find comments by Dr. Roy Poses.

DVT/PE ( deep vein thrombosis/pulmonary embolism) is one such condition. There is no prophylaxis that lowers the attack rate to zero or close to zero. The heparins and warfarin and other non pharmacological preventive measures have not been shown to regularly achieve reductions to less than 10-20%% incidence and in a number of studies studies the treatment arm of a number of randomized trials with various anticoagulants may be as high as 25% to 40%. (for example the 1996 study from several institutions in Canada by J.R. Leclerc reported an incidence of DVT in 36.9% of knee replacement patients receiving fixed dose enoxaparin.See here for details.) If you do hip surgery, knee replacements, spine surgery, or neurosurgery you will have patients with DVTs in spite of the best preventive measure known to man.

Delirium is another event CMS seems to believe that can be totally prevented in hospitalized patients. Dr. Poses discusses the lack of evidence for any really effective preventive measure for this common complication of the elderly who become ill whether or not they are in a hospital.

Ventilator acquired pneumonia is another candidate condition. Again zero incidence is beyond what current knowledge and techniques can achieve.

What is going on when a government agency demands the impossible? What is going on when well meaning professionals attempt to do it? And you know they will. How long was the list of hospitals that refused to play along with the four-hour pneumonia rule?

Is it possible that a government agency charged with payment for medical services for millions of people could be so ignorant of fairly simple medical facts? Are there no folks there who know enough to say "wait, these things cannot be entirely prevented"? At least two medical bloggers suggest what is really going on with this absurd recommendation. Their comments can be found here and here. If it is about quality, we are in trouble with outrageous non-reality based proposals. If it really about saving money and rationing care while pretending to do something else it is another frightening chapter in the play book of covert rationing as explicated by DrRich.

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