I’m worried about what will happen when one aspect pay for performance in Medicare and Medicaid is implemented this fall. The need for effective cost containment strategies in health care is evident. Neither hospitals, providers, consumers or public and private insurers can afford to continue shifting costs around the system in a financial game of Russian roulette. The government as a public payor via Medicare and Medicaid plans to cut costs by stopping payment to hospitals and providers for treating conditions deemed “reasonably preventable.” Sounds like a good idea, right?

When you read the fine print and then look at it in context with the state of our health care system today, this is another health care cost containment measure that will not really contain costs and will potentially result in hospitals losing money to the extent that they will close. My primary concern is that the hospitals that will not be able to meet these standards are those operating in areas with limited resources, such as those in medically underserved areas.

The six conditions included in the list of reasonably preventable conditions are:

1. Pressure ulcers

2. Catheter-associated urinary tract infections.

3. Staphylococcus Aureus septicemia (really hospital acquired venous access infections)

4. Air embolism

5. Blood incompatibility

6. Object left in patient after surgery

I think that some of these are no brainers. If you have a hospital whose surgical staff has problem leaving objects in patients, they need a serious wake-up call. Likewise, if the hospital continual gives patients the wrong blood type, theses are safety standards that MUST be met at a minimal level and no one but the hospital should pay the bill resulting from that error.

On the other hand, probably more morbidity is associated with catheter associated urinary infections, pressure ulcers, and line infections, but they are harder to prevent. It is also hard to prove causality for these events. Any patient with an indwelling catheter is at high risk for getting an infection, even if the staff does everything within their power to prevent infection. Hospitals will test patients for the presence of these conditions on admission and if any of these conditions are present on admission Medicare and Medicaid will pay for the treatment. If a patient did not have a UTI on admit and gets one during the course of treatment, Medicare and Medicaid would not pay.

This concept is great from the standpoint of the need for quality improvement in care to reduce risks for these conditions. There is not greater incentive for the hospital to get busy with their staff to reduce these theoretically preventable conditions than hitting them with a financial consequence. At the same time the a nursing shortage and a primary care physician shortage make it very difficult for hospitals to reach levels of quality that depend on their staff being able to do everything they should do to provide the best quality care.

Pressure ulcers are preventable when nurses and auxillary staff turn at-risk patients every two hours and ensure that nutritional intake is optimized. When I work as a bedside nurse I am obsessed with turning my patient every two hours to prevent pressure ulcers. But I’d be lying if I said there were not times when staffing was so low or other types of care had to be prioritized first that I was not able to do this on every patient every two hours. Is that my fault? Yes and no. If I have 6 patients to care for that all require a high level of care and the auxillary staff called in, I am forced to prioritize care and do the things that are most important first. Now working under those conditions and not being physically able to do everything I want to do for my patients feels horrible. But what other choice do i have? If I have four patients and have support from other nurses with similar patient loads and support staff, I can provide the best care. I feel great when that happens. The reality is that there is a nursing shortage. Nurses will tell you over and over again that they are so short-staffed that they cannot do everything they need to do. Nurses in this situation will also tell you that they ask for help from their administrations constantly. Some hospitals deal with the shortage better than others, but in some geographic areas there is no relief. Will those hospitals be able to meet the quality standards at the same level as other hospitals? Is a hospital in New Orleans suffering from a severe loss of staff and an increase in patients after Katrina be able to make quality improvement at a high enough rate to prevent loss of revenue from treating these catheter-associated infections without reimbursement?

If they cannot, and they have to close, how will that serve the New Orleans community? If you think about the types of hospitals that will have more trouble with this mandate it is important to realize that hospitals with lower quality are often hospitals that serve in areas of high need with few economic resources.

I know that there are many errors that are unacceptable, including some on this list. There are some errors on this list that are less black and white. Preventing those errors falls heavily on the nursing staff that is already overtaxed with responsibility. In areas faced with high shortages and other barriers to making the desired improvements, these mandates will potentially have a large financial impact. I have great concern about the who and where of this financial impact as an indicator of vast disparities in health care along socio-economic lines.