The Medicare No Pay, Never Ever List

The Centers for Medicare and Medicaid Services announced 10 hospital acquired conditions for which it will not reimburse.  The no pay rule has been in effect since October 1.  So, with out further ado: (drum roll):

“Stage III, IV pressure ulcers

Fall or trauma resulting in serious injury

Vascular catheter-associated infection

Catheter-associated urinary tract infection

Foreign object retained after surgery

Certain surgical site infections

Air embolism

Blood incompatibility

Certain manifestations of poor blood sugar control

Certain deep vein thromboses or pulmonary embolisms.”  (List from AMedNews.com Aug 25, 2008).

CMS began to implement the no pay rule October 1, 2008.  Physicians will still be reimbursed for their services, but hospitals will not be reimbursed for their portion of the care.   Now, I don’t know about you, but I agree  some of the events are absolutely “never-ever” events  (retained surgical object, blood incompatibility), but some of the other conditions are out right ridiculous.

My colleagues and I have come up with some ideas on how to respond to this latest demonstration of government “efficiency.”  We have proposed “buttocks rounds”, where the wound RN examines every patient’s behind and charts presence/absence of pressure ulcers.  We thought it especially important to do this on those 35 year old youngsters we are obligated to admit for chest pain.  We also thought that perhaps we could have a “fanny cam” to take pictures, so our documentation would be impeccable.  We advocated noting that all patients had decubs at admission, but the hospital administration shot this one down.

Our next suggestion was that every patient, no matter what, should have an admission urine analysis, to document presence/absence of infection.  There could be a little check-in kiosk where the patient signs in, hands in a credit card for the hefty co-pay, and pees in a cup.  The patients could even dip their own urine, and record it on their check in information to speed the process up and decrease labor costs.  Additionally, we thought surveillance ua’s would be helpful in all patients with urinary catheters, probably daily.  Got to nip that e. coli in the bud!  We also considered putting a mandatory quinolone on every order set for patients with catheters, but became concerned when we realized c. diff may soon be added to the no pay list.  It may be worth a try for now, though!  Too bad about the cost of all those extra ua’s.

As to falls, I have little to offer on prevention of the noscomial hip fracture.  Our hospital uses bed alarms (frequently it requres a doctor’s order, though), and of course we can always get a sitter.  (However, all the hospitals where I work discourage sitters secondary to cost.)  Occasionally we try to get family members to stay with the sun downing patient,  but they rarely do.  Now that Granny is in someone else’s care, they will give some sage advice, like “Don’t use ativan, or haldol, or ambien or seroquel, because Granny gets really nuts with those.  And don’t restrain her either.  Bye.”  They then hurry to the car for their first meal out in months.  Who could blame them? 

CMS is planning on expanding the no pay list to ambulatory settings, nursing homes and home health agencies in 2009. 

I am always in favor of intelligent uses of government regulation, but someone missed the boat.  What do you say we make some fanny cam rounds at CMS?

PookieMD Airlines: How aviation check lists apply to medicine

I am married to an electrical engineer that loves to fly around in a small airplane.  Because I hang out with him, I’ve been forced to observe the intricacies of not crashing into other planes and landing safely.  I’ve learned a lot.

Pilots have a check list for everything.  Plane manufacturers include an entire book of checklists for every contingency, from take off, to landing, to what to do if there is an emergency.  ( It is a BOOK, mind you!)  My husband straps the needed check list to his leg and goes through it every time we land or take off or preflight.  He actually LOOKS at the list, touches each instrument and taps on the applicable gauges.  It is not a passive process.  Hence my hubbie and I have logged over 1000 hours safely in the cockpit of our tiny plane.  (Don’t look at me.  I don’t know a dang thing about flying.  I just kiss the ground when we land.)

Why do we physicians not utilize more check lists as we go through our day?  The medical profession has been (reasonably) stubborn on adapting algorithms and treatment pathways, arguing that each patient is different and no one algorithm can apply to every patient.  But from a patient safety stand point, I will side with the check list every time.  When a patient goes to the OR a check list is utilized, and when a patient is transported in one of the hospitals where I work, there is a “ticket to ride.”  Why don’t we have some simple checklists for ourselves, listing important but (sadly) forgettable to do items for each patient?  Now, some hospitals have an EMR that will generate order sets, but they are usually not as robust as they could be, and frequently only cover one disease state.  These order sets are good, but incomplete, and  lead to “drop offs” on treatment plans.  Hence the need for the check list.

When one of the hospitals I work at transitioned to order entry, I had to develop a check list that I carried around with me, because going back and forth between multiple screens is onerous.  It included the following:

• Order labs for next day (first screen)
• Review current meds (screen #2)
• order new meds (screen #3)
• order radiology studies (screen #3)
• make sure note is entered in the EMR (screen #4)
• review labs (screen #5)
• read other doctor’s notes (screens 6 and more, each note a different screen)
• review radiology studies (screens 7 and 8, depending on if you actually looked at the image.)

It’s quite easy to drop the details we internists live for.  Seems silly, but given it was a new EMR for me, I had to develop a system to make sure my work flow was preserved and important information and procedures were addressed.  Most of us used check lists as medical students, and then gave up the habit as we grew more comfortable with medicine.   You don’t have to have a check list for everything, but it’s helpful when you are encountering a different situation then usual, like the new EMR I described. 

I encourage you to add to your history and physical check list the following things:

• Prophylaxis: e.g. have you written for GI prophylaxis (if warranted) and DVT prophylaxis  (don’t forget that DVT is now one of the  medicare “no pays”)
• “Treatment plan discussed with patient and family, and they are in agreement.”
• Note the time spent with patient and coordinating care.  (A must, for billing.  Heck, have this tattooed on your hand if you can’t remember it!)
• Pressure ulcer present/absent at _____________(location).  (I have a skin category in my physical exam and include the pressure eval here.  Pressure ulcers that develop during a hospital stay are another Medicare no-pay.  More on that in a later post.)

One of my hospitalist colleagues uses the following check list at discharge, necessitated because the EMR we use makes us go between several screens and logins:

• write discharge summary
• write discharge orders
• send note to PCP
• set up follow up
• write scripts

Useful primary care check lists would be:

• State of undress for each exam:  (female pap: the full Monty, male: off with the tighty whities for the prostate check, diabetics: off with their shoes and socks!)
• Check list clipped to chart as to what screenings are done at what age, or in each room.
• Check list on cabinet door detailing what items go in each cabinet.
• Check list at discharge for assistant to review: does patient have scripts, referrals, test info, and know when to come back.
• List of items your front desk staff needs to check at each check in (check address, insurance card, HIPPA).
• List of items your assistant needs to check as they room the patient (chief complaint, allergies, meds etc.)

When I wrote this post,  I considered making a “write post” check list, which would include looking for typos.  It seemed like a good idea, but I wuz too bzy so I didn’t have tim to go threw my list witch wud have reminded me to make sur I didn’t have no tipos.   

We can learn a lot from the world of aviation.    Should we have a check list for Code Blue/COR-0?  Nah, we’re physicians, we know it all.  Besides, the guidelines will change in two years anyway.

Flaps up!