I’m going out on a limb here but in many respects, a patient is not a consumer. Most of the changes in the medical system are based on the consumer model of healthcare. The problem with the consumer model is that medical service is not like buying a product from Wal-Mart. You can’t return it when it malfunctions. There is no lifetime warranty. There are no guarantees. It is almost impossible to compare services of one physician to another. Every surgeon or physician practices a little different. It is difficult to define what is the “best” service or product.

Given the above reasoning and the fact that physicians go to school for about 30 years to become licensed and capable to practice medicine, you can imagine how insane it is to try and compartmentalize medical services into the Wal Mart or Home Depot model of consumerism. If you can sense that I get a little annoyed at this model, it is because I am. I wish that there were smarter people involved in changing the landscape of medicine.

With that in mind, I am going to comment on my previous post about Medicare and its six “Never Pay” items that it will no longer reimburse hospitals for:

1. Pressure ulcers – So if a patient gets a pressure ulcer while in the hospital, the government will not pay for its treatment. For those of you that don’t know, a pressure ulcer is a skin ulceration that forms usually when a patient has been lying down for too long on his back or on some part of his body. The problem with this is that pressure ulcers are extremely difficult to prevent. A patient needs to be turned very frequently in order to prevent an ulcer. Additionally, may patients with microvascular disease such as advanced diabetes or excessive obesity have very bad skin with poor circulation. This is can literally be impossible to prevent.

2. Staphylococcus aureus bloodstream infections/septicemia – These are infections by common skin bacteria that get into the bloodstream. The problem with preventing this is that everyone has these bacteria on their skin. If you have an open wound or are immune compromised you have a high chance of getting this. If you are in a hospital where everybody is sick and nurses and doctors are going from room to room spreading bugs to patients, this is very hard to prevent. I’m not convinced that if a patient gets this while in the hospital it is fair for insurance to deny payment for treatment.

3. Catheter-associated urinary tract infections – Every time a catheter is inserted into a patient, there is a risk of introducing bacteria into the urinary tract that may seed an infection. Sterile technique can minimize the risk of this, but infections still happen with sterile technique due to patient or environmental factors.

4. Objects left in patient during surgery – This is perhaps the one complication where most people agree that payment should be denied for treatment of this, which is usually another surgery for removal of the object. Even though this is malpractice and a big mistake, mistakes happen and I feel that surgery done to correct even a problem such as this should be reimbursed.

5. Air embolisms – These usually occur when air gets into the intravenous access of a patient. This is pretty rare and should not happen but sometimes it does. It’s really hard to account for every bubble of air in every syringe that is used to inject medicine.

6. Blood incompatibility – When the patient gets the wrong type of blood. This is probably the other complication that people most agree should not be reimbursed for. A patient should not get the wrong type of blood. All hospitals use computers and have protocols to ensure that the wrong blood type is not given. However, there are instances, usually in the emergency trauma setting where the wrong stuff gets into the patient.

As you can see, Medicare is in essence dictating the terms of what is reimbursable and non-reimbursable medical care. This is not a good thing for patients or for physicians. To make matters worse, Medicare is considering seven additional items in its “Never Pay” categories. Among them is “falls” while in the hospital. So if a patient falls while in the hospital, the government considers this a preventable complication and will not pay for its treatment.

While Medicare is saying that these policies will improve quality of care, I think it is just going to do the opposite. Healthcare workers are overworked and over-criticized already. Many are moving to specialties that do not involve Medicare or medical insurance reimbursement. Try and find a Neurosurgeon or Plastics or Orthopedic Surgeon to take call at a hospital and you will see what I am talking about.

If the current trend continues, physicians and hospitals will deny care to high-risk patients and will be selective in their provision of care. They may prescribe or recommend lower-risk procedures that may not necessarily be sub-standard, but they will not strive to utilize potentially riskier procedures that may have better outcomes.

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