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CMS “Never Events” Incentivize Physicians To Avoid Caring For High Risk Patients

In 2008, the Centers for Medicare and Medicaid Services (CMS) announced it would no longer pay for the treatment of “never events,” i.e., certain medical conditions in hospitalized patients which the Feds deem to be universally avoidable under all circumstances. These conditions included:

* Decubitus ulcers
* Two kinds of catheter-associated infections
* Air embolism
* Mediastinitis after coronary bypass surgery
* Transfusing patients with the wrong blood type
* Leaving objects inside surgery patients
* In-hospital falls

Then, having been delighted with the results of its original list (or dismayed that healthcare costs continued to skyrocket despite its original list) CMS subsequently proposed declaring several new conditions as “never events,” including: Read more »

*This blog post was originally published at The Covert Rationing Blog*

Medical Ethics And The “R” Word

[Recently] a short article in the New York Times, New Kidney Transplant Policy Would Favor Younger Patients, [drew] my attention to a very basic problem in medical ethics: Rationing.

According to the Washington Post coverage, the proposal comes from the United Network for Organ Sharing, a Richmond-based private non-profit group the federal government contracts for allocation of donated organs. From the Times piece:

Under the proposal, patients and kidneys would each be graded, and the healthiest and youngest 20 percent of patients and kidneys would be segregated into a separate pool so that the best kidneys would be given to patients with the longest life expectancies.

This all follows [the recent] front-page business story on the monetary value of life.

I have to admit, I’m glad to see these stories in the media. Any reasoned discussion of policy and reform requires frank talk on healthcare resources which, even in the best of economic times, are limited.

*This blog post was originally published at Medical Lessons*

Rationed Care, Denied Treatment, And “Death Panels”

One of the canards slung at the Affordable Care Act is that it creates “death panels” that would allow the government to deny patients lifesaving treatments, even though two independent and non-partisan fact-checking organizations found it would do no such thing.

I don’t bring this up now to rehash the debate, but because the New York Times had a recent story on Arizona’s decision to deny certain transplants to Medicaid enrollees — “death by budget cuts” in the words of reporter Marc Lacey. His story profiles several patients who died when they were unable to raise money on their own to fund a transplant. Lacey quotes a physician expert on transplants who flatly states: “There’s no doubt that people aren’t going to make it because of this decision.”

Arizona Medicaid officials told the Times that they “recommended discontinuing some transplants only after assessing the success rates for previous patients. Among the discontinued procedures are lung transplants, liver transplants for hepatitis C patients and some bone marrow and pancreas transplants, which altogether would save the state about $4.5 million a year.” Read more »

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*

New Pap Smear Guidelines: The Right Care Or Rationed Care?

The American College of Obstetricians and Gynecologists (ACOG) recently reiterated their position that Pap smears should be performed on healthy women starting at age 21. This is different from the past which recommended screening for cervical cancer at either three years after the time a woman became sexually active or age 21, whichever occurred first.

How will the public respond to this change?

Over the past year there have been plenty of announcements from the medical profession regarding to the appropriateness of PSA screening for prostate cancer and the timing of mammogram screening for breast cancer. Understandably, some people may view these changes in recommendations as the rationing of American healthcare. Read more »

*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*

Healthcare Rationing: When Is It OK?

In his last post, DrRich considered the differences between a system of healthcare rationing in which individual autonomy is honored, and one in which the good of the collective takes precedence. DrRich concluded that the former is more desirable than the latter, since the latter would amount to throwing aside the Great American Experiment. In response to this post, an astute reader calling him/herself Jupe wrote:

. . in the case of a limited supply of an effective vaccine during a deadly epidemic, it doesn’t weird me out to think of docs and nurses being prioritized over, say, me. Or a hypothetical situation of military leaders being prioritized in the event of bio warfare  So it’s not that collectivism inherently offends me across the board.

In my mind there seems to be some sort of invisible line in there somewhere, but I can’t identify what it’s based on or exactly where it’s at, or why. I just know when it’s been crossed.

Jupe then continues, quoting Ezekiel Emanuel on setting rules for healthcare rationing. Emanuel says, “. . .Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.”

Jupe continues:

[That] just screams “line WAY WAY WAY CROSSED! HOLY CRAP!” to me. I know (well, deeply suspect) there actually is a fundamental difference between “doctors, nurses and military first to be immunized in the event of a bio-warfare attack” and “no antibiotics for the feeble minded” but I can’t pinpoint it outside of “it just intuitively seems right/wrong”.

DrRich interprets Jupe’s question as follows: Why does it intuitively seem OK to ration healthcare in the manner described in the first instance, but not in manner described in the second?

The most obvious answer would be that in the former case there’s an emergency, and extraordinary times call for extraordinary measures. For instance, in times of a war that threatens our survival, most of us would agree that a military draft – perhaps the ultimate sacrifice of individual rights for the good of the collective – is appropriate. And Lincoln, who was fighting a war whose explicit purpose he defined as upholding the Great American Experiment (i.e., to see whether a nation “conceived in liberty and dedicated to the proposition that all men are created equal could long endure”) was himself quite willing to violate individual freedoms to achieve that goal. For instance, he was willing to suspend habeus corpus and jail newspaper editors for sedition. Read more »

*This blog post was originally published at The Covert Rationing Blog*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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