Trying to Make 30 by Pat Conrad MD

Last week, CMS released a study that is, to grossly understate, “controversial.”  In what may be the most damning indictment of government medicine ever produced, a study of the so-called “longitudinal multipliers” of Medicare cost projections claims to demonstrate that average beneficiary longevity beyond a certain “programmatic sustainability threshold” is deemed “counter to the best interests of the elderly population.”  In plain language, the longer Medicare patients live, the worse it is for the survival of the program.  The study’s editors suggest serious examinations of those programs that extend “non-meaningful survivability beyond population benefit goals.”  While the authors do not suggest specific ways to cull the herd, they do call for “innovators [to] … further improving population quality goals over less quantifiable individual encouragements.” 

And admittedly, what you just read above is complete, made-up, parody bullshit.  Hope you enjoyed the link.  But the stuff I made up is not a lot worse than CMS arbitrarily punishing hospitals (and patients) for readmissions within 30 days.  Like all the other made-up, parody, bullshit that passes for “quality metrics”, this particular goal translated into “we’ll save money by not treating sick people.”  Cost overruns never before imagined by the architects of institutionalized compassion have led to desperate attempts to save money, which led to stupid thinking, which we now see, has gotten people killed (okay, this is a real link).  If someone is discharged from the hospital, then odds are they were already sicker than the average Joe.  So being sicker than the baseline population, this person would be more likely to need (re) hospitalization sooner than others.  The answer became to directly financially threaten hospitals, and indirectly threaten doctors, which equates to blaming them for the clinical outcome, absent any evidence whatsoever.

“This financial penalty and public reporting led to hospitals putting pressure on clinicians to reduce 30-day readmissions and keep patients out of the hospital. So, the clinician trying to respond to the pressure and incentive has a patient who is at home and not doing well but they’d been hospitalized 21 days before and you’re in this dilemma. The clinical situation may necessitate hospitalization. You want to do the right thing for the patient, but maybe if I can buy a little more time and leave them at home, take that little extra risk it will work out OK and if they get hospitalized beyond 30 days that is OK.

There are patients being shunted from the ER to an outpatient observation unit rather than being hospitalized because of Medicare policies. Now, that patient can no longer for qualify for home health or skilled nursing facility or other resources because they were not hospitalized.”

Those of us who are actual practicing physicians can see that this weird dis-incentivizing would lead to rationalizing less care for some, in order to help the hospital so that they might help more in the future.  Outcomes can indeed improve with close home follow-up, if it actually occurs, if the patient actually met criteria.  And as the article notes, not a few of these patients are from the lower socio-economic side of the tracks, more likely to be sicker to start, non-compliant, and more likely to earn the treating hospital a penalty for premature readmission.  Every ER has its frequent fliers, and the ones that are already sick tend to come in sick, leading the ED doc to readmit them anyway, whatever the hospital wants or CMS deems.  Sure, some administrators might pay a friendly visit to the ED, just to say hi, no email, nothing written down, just a chance to offer encouragement and maybe a little advice.  The hospitalists won’t like those visits either, squeezed as they are between the clinical (and medico-legal) necessities of the ED and arbitrary CMS rulings.

And yet, here is a study showing that “As many as 10,000 heart failure patients could die prematurely each year because of misguided efforts that keep them out of the hospital to avoid the financial penalties attached to higher readmissions.”

But that only works out to 200 patients per state ever year, which is not too bad, and it is conserving important Medicare resources, right?

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  6 comments for “Trying to Make 30 by Pat Conrad MD

  1. Kyle Rickner
    November 25, 2017 at 1:04 pm

    Let’s not forget our “friends” at the hospital and their role in this. Maybe….just maybe if hospital charges weren’t so obscene these stupid metrics would not be as “necessary”. Why do hospitals get away with murder in the first degree of people’s financial well being? While we talk about Medicare guidlines and worry about not enough people having coverage….nobody talks about the fact that if charges were reasonable….coverage wouldn’t be as necessary and guidlines would not be made up to protect the dollars!

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    • RSW
      November 26, 2017 at 4:06 pm

      ‘Maybe….just maybe if hospital charges weren’t so obscene these stupid metrics would not be as “necessary”.’

      Wishful thinking. Family docs who get pennies from Medicare and Medicaid are getting hit with metrics out the wazoo and then penalized financially.

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  2. Steve O'
    November 25, 2017 at 10:16 am

    This is Fascism, very nearly exactly the core principle of Fascism.
    For if the nineteenth century was a century of individualism … it may be expected that this will be a century of collectivism, and hence the century of the State.
    The corporate State considers that private enterprise in the sphere of production is the most effective and useful instrument in the interest of the nation. In view of the fact that private organisation of production is a function of national concern, the organiser of the enterprise is responsible to the State for the direction given to production.
    State intervention in economic production arises only when private initiative is lacking or insufficient, or when the political interests of the State are involved. This intervention may take the form of control, assistance or direct management.

    (Benito Mussolini. var. sources)
    We are so accustomed to Fascist thought, we hardly see that there is much about Fascism that our current existence endorses. In the press, of course, we are all “pro-freedom” and “pro-individuality.” Paradoxically, we are trained to say these things instinctively. We are not encouraged to dwell on what freedom actually means; just endorse the label and don’t worry about it.
    Medically, the individual in a Fascist state can be best described as a productivity-versus-time curve. Other people’s energy and productivity are used up by children until they can produce for the State as well. An individual reaches the break-even point in youth, when their productivity becomes more than only what they use up. They stay positive, producing things for the State. Sooner or later, they age out and no longer produce more than they consume; they go negative. If it is a question of aging, they will never again be productive. They have become a drag on society, and are simply burning up whatever invested capital the State has from their prior productivity in food, bedsheets, etc. Of what interest is the state in preserving these wheezy old machines that are long obsolete, and cost more to run than they make in product?

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    • Pat
      November 25, 2017 at 11:24 am

      Exactly Steve!! Which is why I forever have a deep hatred for Medicare. In public forums, I have had angry retirees state that doctors who would do away with Medicare should have their licenses stripped. It is so depressing seeing those that defeated Fascism and Communism abroad embrace these evils at home.

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  3. Perry
    November 25, 2017 at 9:36 am

    And yet, here is a study showing that “As many as 10,000 heart failure patients could die prematurely each year because of misguided efforts that keep them out of the hospital to avoid the financial penalties attached to higher readmissions.”

    Yes, culling the herd is about right…

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    • Steve O'
      November 26, 2017 at 12:47 am

      In the world in which humans have no value except as sources of productivity for others – that is, slavery- direct patient care would be inconceivable. How can an individual determine their own worth to oneself? CMS must assign the value of your care and if it is worthwhile to the community.

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