AMA House of Delegates

AMA meeting: Delegates decry CMS no-pay list as unrealistic and call for revision

Physicians said many conditions are not truly preventable and the initiative will expose doctors to additional liability.

By Doug Trapp — Posted July 7, 2008

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The AMA House of Delegates in June stood solidly against much of a Medicare initiative that would limit pay beginning Oct. 1 for up to 17 hospital-acquired conditions.

Under the program, Medicare still will pay for hospitalizations but no longer will reimburse facilities for the added cost of care for certain preventable conditions that patients develop during their stays. But delegates said the conditions on the Centers for Medicare & Medicaid Services' list are not always preventable, even if physicians follow evidence-based guidelines. The effort threatens to increase defensive medicine, to drive up costs by requiring more tests upon admission, and to expose physicians to additional lawsuits, doctors said.

"This is a fundamentally flawed program about which our concerns cannot be expressed stringently enough," said AMA Board of Trustees member Steven J. Stack, MD, an emergency physician in Lexington, Ky.

The house adopted policy at its Annual Meeting calling on the AMA to oppose nonpayment of conditions that are not reasonably preventable with the application of well-developed evidence-based guidelines. The new policy asks the Association to inform physicians about the effort, to monitor practice changes resulting from the initiative, and to educate Congress, CMS and the public about its unintended consequences.

CMS, instructed by the Deficit Reduction Act of 2005, identified eight conditions for which Medicare would not pay beginning Oct. 1, 2008. CMS finalized that list in October 2007, but in April 2008 the agency called for nine additional conditions to be added. CMS accepted comments on the new proposal until June 13 and will respond to them in a final rule due on or before Aug. 1.

These efforts are an attempt to make Medicare a prudent purchaser of health care services, CMS Acting Administrator Kerry Weems said in April. A CMS spokeswoman said conservative estimates suggest $270 million in savings over five years.

Michael Greene, MD, an alternate delegate for the Medical Assn. of Georgia and a family physician in Macon, Ga., said the effort creates unrealistic expectations. "What these requirements do is not hold us to a standard of care. It holds us to a standard of perfection." For example, it's not reasonable to assume physicians can prevent all urinary catheter-associated infections -- one condition on the no-pay list, he said.

The program will cause problems if it's not clear who is responsible for the patient developing the condition, said Louito Edje, MD, a family physician in Maumee, Ohio, and an AMA Organized Medical Staff Section member. "This potentially is divisive for the health care team."

The AMA also should be concerned that CMS will apply this philosophy to physician practices, said Richard Warner, MD, a psychiatrist in Shawnee Mission, Kan., and an alternate delegate for the Kansas Medical Society. "We need to put forward the strongest possible opposition to the continued growth of this approach."

In addition, the house adopted policy against allowing public or private insurers' payment practices to determine care standards. It instructed the AMA to study the initiative's impact on professional liability and its potential for micromanagement of physician decision-making.

AMA: Too many conditions

CMS should make a number of adjustments to the Medicare hospital-acquired conditions program, such as excluding eight conditions that do not meet the statutory requirement of being reasonably preventable, wrote AMA Executive Vice President and CEO Michael Maves, MD, MBA, in a June 13 letter to CMS.

For example, the program should not include delirium, which can have many potential causes and is common near the end of a patient's life. Seven other conditions aren't reasonably preventable, Dr. Maves wrote. These are: surgical site infections following certain elective procedures, Staphylococcus aureus septicemia, Clostridium difficile-associated disease, ventilator-associated pneumonia, deep vein thrombosis/pulmonary embolism, Legionnaire's disease and extreme aberrations in glycemic control.

CMS should consider excluding high-risk patients from the effort and should determine how preventable these conditions are, Dr. Maves wrote. The agency should factor in the extra costs of complying with this program -- including screenings and tests -- in the physician pay formula.

A better approach would be for CMS to ask hospitals to comply with evidence-based care guidelines and deny payment only if these standards were not followed, Dr. Maves wrote. Under such a system, Medicare still would pay for the additional care required if the standards were followed and a patient still developed one of the conditions.

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ADDITIONAL INFORMATION

Medicare's no-pay list

The Centers for Medicare & Medicaid Services on Oct. 1 plans to no longer reimburse hospitals for the added costs of treating at least eight hospital-acquired conditions. CMS has proposed an additional nine conditions that may be included on the list.

Initial 8 conditions

  • Pressure ulcers
  • Catheter-associated urinary tract infections
  • Vascular catheter-associated infection
  • Mediastinitis after coronary artery bypass graft surgery
  • Air embolism
  • Blood incompatibility
  • Object left behind in surgical patient
  • Certain types of falls and trauma

Additional 9 conditions

  • Surgical-site infections after total knee replacement, laparoscopic gastric bypass and gastroenterostomy, or ligation and stripping of varicose veins
  • Legionnaires' disease
  • Diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma or hypoglycemic coma
  • Iatrogenic pneumothorax
  • Delirium
  • Ventilator-associated pneumonia
  • Deep vein thrombosis or pulmonary embolism
  • Staphylococcus aureus septicemia
  • Clostridium difficile-associated disease

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Meeting notes: Medical practice

Issue: With more practices operating on a cash basis, physicians worry that some patients may not know the fees, or how they areexpected to pay them.

Proposed action: The AMA is to adopt principles for a cash-based practice that include an appropriate fee schedule that is understandable and easily accessible to patients. Cash-based practices should encourage patients to have health insurance coverage for catastrophic illnesses. [ Adopted ]

Issue: Medicare rules prohibit patients from compensating physicians above and beyond what Medicare covers, which may discourage physician participation.

Proposed action: The AMA will immediately call upon Congress to remove fee limits under Medicare and to preempt state laws limiting charges for physicians. Progress is to be reported annually to the house. [ Adopted ]

Issue: Antiquated federal rules pose barriers to electronic prescribing.

Proposed action: The AMA will work with federal and private entities to update laws and rules that are roadblocks to e-prescribing, while maintaining a position that physician Medicare or Medicaid pay not be reduced for failing to adopt e-prescribing. The AMAwill begin discussions with the Drug Enforcement Administration to allow e-prescribing of Schedule II drugs. [ Adopted ]

Issue: Physicians can't always access patient's preexisting prescriptions for controlled substances.

Proposed action: The AMA will support changes to state prescription drug monitoring programs to allow physicians real-time access to their patients' controlled substance prescriptions across state lines. [ Adopted ]

Issue: Physicians sometimes have limited knowledge of their rights under Medicare's Recovery Audit Contractor program.

Proposed action: The AMA will support a moratorium on theexpansion of the RAC program and begin a physician education campaign. [ Adopted ]

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