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A Reasonable Challenge

Maureen Larkin, for HealthLeaders Media, August 7, 2008

There's been a lot of debate lately about whether the conditions on CMS' no-pay list are preventable in every case. Some wonder whether the agency is asking the impossible.

But the discussion shouldn't be about whether the agency is asking healthcare organizations to reinvent the wheel, says Gene Burke, vice president and executive medical director of clinical effectiveness at Sentara Healthcare in Virginia. It should be about the patients who will be better served with these regulations.

"If you look at the document that CMS released... they bring up the fact that people have said that they don't know they're all preventable. CMS acknowledges that, and says that in future rule making, it will work to identify procedures that can be considered reasonably preventable," Burke says.

In other words, CMS realizes that the three additions to the no-pay list—deep vein thrombosis, surgical site infections resulting from elective orthopedic or bariatric procedures, and complications from poor blood sugar control—will still occasionally occur, but it is using its influence to force hospitals to put procedures and processes in place that will do everything reasonable to prevent it.

"Will we be able to eliminate all infections? Not likely," Burke says. "Should we work to get as close to zero as we possibly can? Yes. We may not know exactly how much of a reduction we can achieve, but that doesn't mean that we shouldn't work at it."

Beyond the work that will go into "reasonably preventing" these conditions, Burke encourages his fellow quality and safety executives to see opportunity, as well. Monitoring the blood sugar levels of patients presents all organizations the opportunity to not only prevent complications, but also educate patients who are at risk for diabetes about proper nutrition and exercise.

"While we can't force people to do the right thing, we can make a greater effort to educate them," he says.

As diabetes reaches epidemic proportions in our country, Burke hopes that CMS' requirements will refocus healthcare's attention on a problem that carries very high risk for patients.

"Because diabetes is so frequent a problem, caregivers at every level have lost an appreciation for just how important hypoglycemic management is," he says. "Its frequency has dulled our appreciation of that."

And while extra efforts will have to be made in every hospital to ensure that hospitals are eligible to receive every penny of their Medicare reimbursement, Burke says doing everything reasonable to prevent the 11 no-pay conditions from occurring will more than make up for the time and money spent.

"Will it be a challenge? Absolutely. I for one am confident that the savings achieved by the avoidance of complications should more than offset the cost of the effort," he says.


Maureen Larkin is quality editor with HealthLeaders magazine. She can be reached at mlarkin@healthleadersmedia.com.


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