Friday, January 14, 2005


Medicrazy: Part II

Since I picked at the festering wound I carry over some aspects of my profession, I find myself in a surly enough mood to poke another stick at the 800 pound gorilla called Medicare.

As I had stated in an earlier post, Medicare pays hospitals on a DRG (diagnostic related group) basis. Every diagnosis has an associated weight. The weight relates to how much reimbursement the hospital receives from Medicare. Usually, no matter how long a patient may stay, or what other complications arise, the hospital receives only that one payment (example: admitted for Hypertension then develops cerebral infarction during the stay, the hospital only gets reimbursed for the Hypertension diagnosis).

One diagnosis that has received much government attention is gram negative pneumonia (GNP). Due to the specific populations affected and the expensive antibiotics to needed to treat GNP, Medicare allows for a different DRG (79) and a higher reimbursement than with simple pneumonia (around 2,000 dollars more). That was the idea anyway, the reality is much different.

The government is always looking for ways to cut, what they call, "waste" out of Medicare and make it less costly. The Office of the Inspector General (OIG) is the Gestapo arm of Medicare that sniffs out fraudulent claims made by any institution that might bill Medicare for services provided.

The OIG, some years ago, mounted a crusade against what they believed was overbilling of GNP by hospitals. Interestingly enough, the OIG just happens to receive a percentage of the recovered funds to Medicare when "fraud" is found. Nice game, ain't it?

The list of DRG's at "risk" for being up-coded has since, not surprisingly, grown to include about 6-8 different diagnoses. So now we practice in this schitzophrenic environment where we treat for one diagnosis, but document another to avoid a review and accusations of fraud.

What the government realized, and exploited, is that many diagnoses are made clinically since there is no confirmatory tests available. Like with GNP and regular pneumonia, a clinician is rarely able to culture the causative organism (only about 20% of the time) so we decide what organisms to cover based on a number of separate factors (other diseases the patient has, age, Immune status, etc.).

The clinician may know that a certain patient's pneumonia is likely caused by a gram negative organism, may treat them with the more expensive antibiotics to cover the organism(s), but since no confirmatory cultures could be obtained, the clinician is playing with fire if they actually document their thoughts. In the end the hospitals have to eat the expense of treating a diagnosis they aren't allowed to bill for.

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