Post-Vacation Potpourri: Items Interesting, International, and Ineffably Sad

Just returning from a work-acation, including a talk in Buenos Aires. Today I’ll briefly cover a few items: Medicare’s final “no pay” list; patient safety in Argentina; a great post on hospital finances; and one of the saddest things I’ve ever experienced.

First, the final “no pay” list. I’m not sure if this was CMS’s intent, but their trial balloon of possible additions to the “no pay” list included so many ludicrous items that the final list seems nearly rational. You’ll recall the proposed list; yes, the one that made me near apoplectic: including such easily measurable and preventable entities as Legionnaire’s disease and delirium. Luckily, these and some of the other wrongheaded items were jettisoned somewhere inside the sausage factory of CMS’s Baltimore HQs. The final list includes just three new entities:

  • Certain Surgical Site Infections Following Orthopedic and Bariatric Surgeries
  • Hospital-acquired Hypoglycemia and Hyperglycemia
  • Deep Venous Thrombosis or PE Following Joint Replacements

Before you get too peeved, remember how this list will actually be used. Take the example of hypoglycemia. Previously, if a patient developed hypoglycemia in my hospital (and didn’t have it on admission), I could add it as a “complicating condition” to the primary diagnosis (say, heart failure) and get paid about 50% more by Medicare. Since there is a pretty good chance that hypoglycemia developing in my hospital was caused by the hospital (an overdose of insulin, usually), withholding that extra payment seems kosher to me. Ditto for hyperglycemia.

Surgical site infections and DVT/PE are trickier. Let’s focus on DVT to illustrate the point. We know that DVTs are partly preventable through assiduous implementation of safety practices (early mobilization, anticoagulant prophylaxis, or leg squeezers), but only partly. Let’s say a patient gets a DVT after surgery, despite my hospital having done everything recommended in the literature to prevent it. Is there any reason that we should not be compensated for the additional cost of caring for that DVT?

I discussed this with a high-ranking CMS official last week. What should CMS have done, he asked? I know it would be administratively unwieldy, I said, but I think that DVT should have been the first test measure of a process-outcome diad. In other words, a hospital would not be able to claim DVT as a complicating condition if: a) the patient developed a DVT (the bad outcome) AND b) there was no evidence of appropriate antecedent prophylaxis (the missed processes). The CMS official was receptive to this idea; we’ll see where it goes.

Overall (and how’s this for faint praise), the list is far less bad than I feared it would be. That’s good, since it appears that most private insurers are following CMS’s lead. As my colleagues and I have written previously (here and here), this policy direction itself is sound (the initiative is certainly getting everybody’s attention, far out of proportion to its relatively puny financial impact). If CMS can just get the details right, it should make patients safer.

For now, however, I believe that CMS should have started much smaller – with a couple of easily measured diagnoses (such as central-line bloodstream infections and retained foreign bodies after surgery) that have clear preventability and few “present on admission” issues – and studied the program carefully before broadening it. Because they started with such a long and problematic list, I predict major backtracking within two years. We’ll see.

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A few quick notes from my trip last week to Buenos Aires. I was invited there by my old friend Matias Milberg, a wonderful internist and hospitalist who works at CEMIC, one of Argentina’s top hospitals/health systems. BA is delightful if you like big international cities: it is sprawling, fast paced (the lane markings on the roads are there for decoration only, as far as I can tell), and a bit sooty. But it is blessed with nice weather, world-class architecture and public art, and delightfully warm people. I was only there for a few days, and never quite got into the swing of the greeting hug (far nicer than a handshake) and having dinner when I’m usually bedding down to watch The Daily Show or Letterman. It would have been great to have had more time.

In terms of patient safety, Argentina straddles the developed and developing world. While there are some people (like Matias) who are far advanced in their thinking about safety and quality, these folks are supported by relatively few systems and resources. There is little-to-no transparency (nothing is publicly reported), minimal healthcare regulation, and not much in the way of computers. In other words, it resembles the U.S. a decade ago. This means that many of today’s safety initiatives are focused on sensitizing people to things like handwashing and safe medication practices.

That said, there is a lot of excitement about patient safety: about 250 people attended the safety conference I spoke at, from all over Argentina and even from other South American countries. I can now see why the WHO’s World Alliance for Patient Safety may prove to be a crucial organization, since practices and policies must be feasible in under-resourced healthcare systems.

Overall, I left Argentina quite hopeful – they are hungry for knowledge and poised to make things better. Plus, it’s a great place to buy a leather jacket.

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Paul Levy, the CEO of Boston’s Beth Israel Deaconess Hospital, has developed a well deserved following for his leadership, his transparency, and his blog, “Running a Hospital.” Paul’s recent posting on how a CEO thinks about budgets and finances is a must read for those who work in hospitals and are impacted by these very tough decisions. Check it out.

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Finally, the saddest of notes. Fred Masoudi and Marie Johnson were two of my favorite UCSF residents when I was residency director in the early 1990s. Both are stellar doctors and wonderful human beings – the kind of people that can make you proud of our field. Fred is now a prominent cardiologist at the University of Colorado; Marie, his wife, is an outstanding general internist at Denver’s Kaiser Permanente.

Last week, they traveled to tiny Gearhart, Oregon for a relaxing vacation with Marie’s sister and family. On the morning of August 4th, their world collapsed.

At 6:30 am, a private single-engine plane, flying in the morning fog, crashed into the rented house, instantly killing two of Fred and Marie’s three children, Sam and Grace, ages 12 and 8. Remarkably, the parents were at a nearby house with their third child, Elizabeth, at the time of the crash, and all three survived. I get chills thinking about what it must have felt like to hear the crash and see the house burning. Unimaginable. Also killed were Sam and Grace’s 10-year-old cousin, as well as the pilot and passenger on the plane.

I wanted to write this in case any of their old friends and colleagues had not heard this terrible news. Marie and Fred’s family and friends have put up a blog – it is here, and the kids’ school has an informational page here. A memorial service is planned for next week, and they have established a memorial fund at the school:

Sam and Grace Masoudi Memorial Fund
St. Anne’s Episcopal School
2701 S York St.
Denver, CO 80210

A few days ago, Fred wrote to many of the family’s old friends – his note has been widely circulated so I feel comfortable sharing it with you. He concluded it with this remarkable paragraph:

… we know that it will be awkward when we see each other again. It is my hope that our friends and colleagues will be able to overcome this awkwardness rather than avoid it. Asking us how we are, and speaking of Sam and Grace will not increase our suffering. We ask that you continue to speak of them, to ask us about them so we can tell their stories, our story – this is something that will always be on our minds. Please reach out to us, and to live with us when we cry. We are so grateful to have friends to support us because so much was taken away from us.

I hope you’ll consider making a donation to the Memorial Fund. And do say a prayer for these extraordinary people.

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