(The "comments" link above does not send to Medicare; it just puts comment on this page.)
Medicare wants comments by September 8 on fining hospitals in a quarter of metro areas, if their patients who get knee or hip replacements have total Medicare costs above average. "Total" includes costs far beyond the joint replacement, since it includes continuing treatment of pre-existing chronic conditions, like diabetes, dialysis, AIDS, etc. (here, here, and here).
This is rationing by denial of costs: patients with chronic diseases would continue to have above-average costs even after perfect joint replacements, which hospitals cannot afford. So they will hear, "You are not a good candidate for joint replacement." Yet these chronically ill patients especially need the improved mobility and ability to exercise that a joint replacement can provide. Medicare acknowledges that hospitals will try to reduce costs as part of this program, which is why they exclude their favorite technologies, "We do not believe it would be appropriate for the CCJR model to potentially hamper beneficiaries' access to new technologies."
The Center for Healthcare Quality and Payment Reform has a good analysis. Patients with above-average Medicare expenses would be able to avoid the lack of local treatment by going outside their area, reminiscent of the days when divorce or abortion were legal in some states, and people traveled to get them. The adopted final program lists the areas covered in a table. As usual Medicare excludes Maryland, where Medicare has its headquarters and many Medicare family members and retirees live. This time they exclude Washington, DC too. They cover New York City and much of New Jersey, so patients will need to go upstate, or to Connecticut or Long Island. They cover Los Angeles and Orange counties, so patients will need to go to Ventura, Santa Barbara, Riverside, San Bernardino or San Diego. It will be interesting if orthopedists get hospital privileges in those outer counties, to treat their higher-cost patients.
However hospitals and doctors will not be able to tell sicker patients that they might easily get treated in another county, since Medicare will monitor and penalize their efforts to shift care. Patients will have to find out on their own, while lacking mobility because of the poor joint.
"An unintended consequence of a payment model such as (this) may be the 'cherry-picking' of low risk patients," according to a February article written by Drs. Alexandra Page and Mary O'Connor, posted on the website of the American Academy of Orthopaedic Surgeons. "Health systems and surgeons will be subject to financial incentives to avoid patients at higher risk of complications and hence, more expensive care." The two doctors are being polite to call it "unintended." Medicare has been warned about cherry-picking repeatedly, so it is clearly Medicare's goal.
You can read comments on new incentives for Accountable Care Organizations to reduce care, which were due September 2, 2014, including mine.
At the same time the Center for Healthcare Quality and Payment Reform provided substantial and critical comments on other aspects of hospital payments which can hurt patients.
You can read comments on hospital payments which were due June 30, 2014, including mine.
The public submitted comments to Medicare's 2013 rules by June 25, 2013, and you can read them, including mine.
The American College of Surgeons commented to Medicare that doctors and hospitals do reduce care when they respond to readmission penalties and other incentives:
80 Members of the House of Representatives have co-sponsored bill HR 4188, which redefines readmissions to omit "transplants, end-stage renal disease, burns, trauma, psychosis, or substance abuse." This change protects those patients, but half the hospitals will still be above the national average, pay large penalties, and have incentives to deny care to fragile elderly outside these protected classes.
Please support a better fix: ask Congress to change HR 4188 to redefine "excess readmission" in1886(q)(4)(C)(ii) rather than "readmission" in 1886(q)(5)(E). This technical difference means the national average would not change, and the narrower definition of "excess readmission" means far fewer hospitals would be above that national average and face penalties.
4 Senators have introduced a bill to adjust readmissions for income, education, and poverty rate of the patients or neighborhood of the hospital, so hospitals which serve poor or poorly educated patients are not penalized.
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