Comarow On Quality

You're unlikely to be surprised to hear that hospitals are routinely paid for indifferent or bad care, but did you know that it is implicitly built into the Medicare system? Say a Medicare patient is admitted for surgery, develops an infection because of sloppy post-surgical care, and has to stay several days longer than expected. The hospital will be reimbursed for at least some of the expenses due to its own failings.

This is because the infection is considered a complication under current Medicare rules, and hospitals are paid for treating complications. One way is for the complication to be recoded into a higher-reimbursement category. The other is that hospitals get back 80 percent of the amount above a threshold that changes every year (it's $24,485 for 2007). So if the infection generates extra costs of $75,000 (which isn't difficult these days), the hospital eats the first $24,485 but gets back 80 percent of the remaining $50,515, or more than $40,000. That's how it's been for decades. Is that crazy or what?

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I'm still ungritting my teeth and untensing my body (is that a word?) after last week's Food and Drug Administration hearings about risks that might or might not be posed by the diabetes drug Avandia. If you skipped over the news coverage because diabetes isn't an issue for you or your family, the point I want to make today is that whether it's Avandia for diabetes or some other drug taken for some other chronic condition, the bottom line is that there's no bottom line.

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I never get used to it, no matter how often it happens. Somebody tells me he needs surgery. I suggest asking the surgeon how many times she's done the procedure. "Really?" he says, clearly surprised. "You can ask a doctor to give you numbers?" No matter what kind of surgery or whether the setting is a hospital, an outpatient clinic, or a doctor's office, the principle is no different for surgeons than for musicians or tennis players: Practice counts. If it didn't, we'd have medical students do the surgery when the veteran cutters are out of town. They'd charge less, too.

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How good is your local hospital at hand-washing? Administrators might—or might not—be tracking how faithfully their doctors, nurses, and other caregivers disinfect their hands with soap and water or an alcohol gel before touching patients. Either way, just try asking for this information. Good luck. How about the frequency of patient falls? Good luck again.

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