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
- ANNUAL MEETING 2008
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Chicago -- 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.