Fay and Aunt Mae

Look like it is going to be mostly wet in South Florida the rest of today and maybe tomorrow as Fay moves over land. They are already feeling the rains in what is predicted to be 4-8 inches falling on an already soaked (from a wet summer) South Florida. But it was enough to have schools canceled and a full blown preparation order from the governor. As one official said it, "it's great practice for the big one." Those involved in disaster preparation are doing their thing, their kids are at home or with friends since the plans didn't include the storm. Hopefully everyone will be ok, and Fay will just slide by. I hope my friends in NC are watching out now...this ain't over.

Interesting development in U.S. socialized medicine today (yes dear, there is socialized medicine in the U.S.; it just doesn't call itself that).  Medicare finalized a list of types of conditions for which, starting Oct. 1, it will no longer reimburse hospitals at the higher diagnosis-related group rate. Hospitals (not the physicians who care for them) will be paid much less for these patient conditions:

• Stage III, IV pressure ulcers
• Fall or trauma resulting in serious injury
• Vascular catheter-associated infection
• Catheter-associated urinary tract infection
• Foreign object retained after surgery
• Certain surgical site infections
• Air embolism
• Blood incompatibility
• Certain manifestations of poor blood sugar control
• Certain deep vein thromboses or pulmonary embolisms

OK I get the point. Anything iatrogenic (hospital or clinician induced) needs to be stopped. Medical error needs to be curtailed and not encouraged, but there are issues on this list that are not as straight forward as to be responsive to "if we don't pay, it'll go away." I know there is going to be some debate on this, but let's just take the first one....Stage III, IV pressure ulcers. I understand that there is the perspective that they should never get to this stage, but that may be more dependent on the patients milieu for healing and not what is being done to or for the patient.

So nurses in skilled nursing homes are at an all time low...ratio of nurse to patient. There just aren't enough. The paucity of geriatricians to take care of an every growing population of elderly is significant. They are calling for 1000's needed over the next 20 years. Nursing homes are understaffed, overworked, underpaid and my fictitious Aunt Mae is there.

Aunt Mae doesn't eat well, maybe not nutritionally what she was in her 20's, and sits in a wheel chair most of the day. She is moderately cognizant of her surroundings for only a few hours a day. She is transferred periodically from chair to bed and back by the nursing assistants when they think about it, and after they feed, dress, bathe etc everyone in the unit.

Pressure sores result from sustained pressure on the body. They're especially common in areas that aren't well padded with muscle or fat and that lie just over a bone, such as your spine, tailbone (coccyx), shoulder blades, hips, heels and elbows. Because your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients, and irreversible damage and tissue death can occur. Though the affected tissue may die in as little as 12 hours, the injury may not be apparent for days or even weeks.

So one day, the staff, PA, NP or physician sees the damage...the start of the ulceration (because they performed an earnest, deliberate, complete examination. Best case is that aggressive care at this stage prevents further damage and the Stage 1 (early) sore heals. In most cases, it doesn't heal. Aunt Mae doesn't have the nutritional constitution or immune system to heal or fight off infection from the less than sterile conditions that are at ALL nursing homes. So, she is transferred to Geriatric General Hospital for more definitive, attentive care. She gets it, and heals.

Now, the hospital wants to get paid. Under the new rules, the hospital is made "responsible" and gets paid much less than the care provided because of the diagnosis (which provides no leeway for explanation of the events) code placed on the claim form to Medicare. Later the hospital has to make a decision about the care they will provide and decide to eliminate the "losing" diagnosis and declare that they will no longer accept bed sore patients for care, and the nursing home (the same one where the problem started) takes over long term care. The problem gets worse.

This is of course a hypothetical with real world consequences. I get what Medicare is trying to do, but they are so confused on how to get there. The system is really broken. We can't continue on this route. Medical care will continue to be costly, and increasingly ineffective if we use these methods to fix the global problems. It is time for real socialization at some level to eliminate the barriers to healthcare that have been and continue to be created. What is more likely is an interest in ways of preserving income by various and sundry methods to get paid for the work done and the material expended.