Hospitals Face Tough Decisions When Treating Illegal Immigrants

There are no winners when problems within the immigration and healthcare systems collide, as the result often is costly and tragic for hospitals and patients. In its August 3 issue, The New York Times outlines several cases in which hospitals must repatriate seriously injured or ill immigrants because nursing homes are unwilling to accept them without insurance. In many cases, the only alternative to repatriations is keeping patients indefinitely in acute-care hospitals.

Medicaid does not cover long-term care for illegal immigrants or for newly arrived legal immigrants, creating a quandary for hospitals, which are obligated by federal regulation to arrange post-hospital care for patients who need it. American immigration authorities play no role in these private repatriations, carried out by ambulance, air ambulance and commercial plane. Most hospitals say that they do not conduct cross-border transfers until patients are medically stable and that they arrange to deliver them into a physician’s care in their homelands. But the hospitals are operating in a void, without governmental assistance or oversight, leaving ample room for legal and ethical transgressions on both sides of the border.

Many hospitals engage in repatriations of seriously injured and ill immigrants only as a last resort. Other hospitals are more aggressive, routinely sending uninsured immigrants, both legal and illegal, back to their homelands. Read the full article from The New York Times.

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Is Pay for Performance Working?

A new analysis of quality incentives published in the July/August issue of Health Affairs suggests that pay-for-performance programs may have a less-than-expected impact on quality. The article compares 81 Massachusetts physician groups eligible for quality incentives with 73 that are not.

The study found that overall performance from 2001 to 2003 improved in 73% of preventive care measures. But the performance of the 5,350 physicians analyzed was statistically indistinguishable. Everyone's quality improved, regardless of whether the physician group stood to earn a bonus, which ranged from $200 to $2,500 per quality measure for an individual physician, depending on the health plan.

Even so, some pay-for-performance efforts have shown results. A Centers for Medicare and Medicaid Services (CMS) evaluation of its Physician Group Practice Demonstration found that all 10 participating practices hit or exceeded targets on at least seven of 10 quality metrics of diabetes care. American Medical News outlines several studies that argue for and against pay for performance while addressing the future of payment reform. In its proposed rule released July 31, CMS said it will require hospitals to report on 13 more quality measures under the inpatient prospective payment system in 2009.

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SCCM Help Keep Some HACs Off Medicare's No-Pay List

The Centers for Medicare and Medicaid Services (CMS) announced July 31 that it will no longer pay for extra-care costs stemming from poor control of blood sugar levels, from blood clots following knee or hip replacements, or from surgical-site infections following certain orthopedic and bariatric surgeries. However, the list of no-pay conditions was much shorter than expected. Medicare had considered not paying for seven additional preventable errors. Pressure from the Society of Critical Care Medicine (SCCM) and other specialty societies is being credited with keeping other hospital-acquired conditions (HACs) related to critical care off the list.

SCCM, along with representatives from the American Association for Respiratory Care, the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the National Association for Medical Direction of Respiratory Care, developed a detailed letter to CMS acting administrator Kerry Weems expressing concern about the proposed changes to the hospital inpatient payment system.

The letter outlined a great concern within the medical community -- certain infections cannot reasonably be expected to be totally eliminated. Some HACs will always be possible despite the strictest adherence to evidence-based guidelines. The letter outlined reasons why ventilator-associated pneumonia, iatrogenic pneumothorax, deep vein thrombosis/pulmonary embolism, and delirium in the intensive care unit cannot be considered 100% preventable. In some cases, the effect of preventive measures is unclear or no evidence-based guidelines exist. The societies do not believe CMS has the authority to adjust payment based only on the presence of these HACs.

Disappointment still abounds about the addition of any condition to the no-pay list that is not considered a “never event.” The American Medical Association released a statement expressing its protest. “We are working hard to improve quality and efficiency, but simply not paying for complications or conditions that, while regrettable – are not entirely preventable – is not the way to do it. In the race to improve healthcare quality, [the U.S. Department of Health and Human Services] is confusing events that should never happen, such as wrong-site surgery, with often unavoidable conditions, such as surgical site infections. To be reasonably preventable, there should be solid evidence that by following guidelines, the occurrence of an event can be reduced to zero or near zero. This is not the case for many of the now-banned conditions.”

The Society thanks all those involved in developing the letter to CMS and looks forward to working closely with organizations on measures to improve patient care.

Other Advocacy News
The SCCM Advocacy Committee recently played an instrumental role in correcting an error in a CMS policy regarding the appropriate billing for critical care services. While Transmittal 1548: Medicare Claims Processing should not be viewed by local Medicare carriers or physicians as a change in policy, it is helpful to critical care practitioners for both ongoing billing questions as well as in defending any audits of past billings. The key points of the transmittal, as well as an in-depth copy of the CMS document, are available here.

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Advance Registration Ends Soon for Venous Thromboembolism Conference

Register today to guarantee your spot at the Society of Critical Care Medicine’s (SCCM) latest event in the Clinical Focus series, Venous Thromboembolism in the Critically Ill and Injured, to be held September 4 and 5, 2008, in Boston, Massachusetts, USA. Pre-registration will be accepted only until Friday, August 15, 2008.

Receive expert guidance on the prevention and treatment of venous thromboembolism (VTE) from well-respected thought leaders who are practicing nurses, pharmacists and physicians. Using an interactive format, expert faculty will cover topics including:

• Epidemiology and prevention of venous thromboembolism
• Evidence-based approaches to prophylaxis
• Evolving approaches to therapeutic modalities and complications

Help prevent VTE in your hospital and register today. For more information, download the course brochure.

Additional Resources
The Society has several resources on the topic of deep vein thrombosis (DVT) available at LearnICU.org.

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SCCM's Congress: An Affordable and Accessible Educational Experience

During a time when a slowing economy is on everyone’s mind, the Society of Critical Care Medicine (SCCM) brings you quality, affordable education at its 38th Critical Care Congress, the largest multiprofessional critical care event of the year.

Join your colleagues January 31 through February 4, 2009, in Nashville, Tennessee, USA. Along with a beautiful, temperate climate throughout the year, Nashville is a convenient driving distance from many of the nation's major cities – nearly 50% of the United States’ population lives within a 650-mile radius of Nashville. There also are numerous inexpensive flights to and from the Music City.

The 2009 Congress curriculum will be packed with world-renowned speakers, interactive workshops, thought-provoking panel discussions, stimulating educational sessions and the opportunity to earn continuing education credit. You also will find more than 150 exhibiting companies, featuring the latest technology, products, services and career opportunities. With so much in one place, this year’s Congress is certain to be simply the best!

Register for Congress today! For additional information or to download the preliminary program, click here.

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Is Therapeutic Hypothermia in the Critical Care Setting Appropriate?

Cases in which individuals survive falls into icy waters or avalanches have led researchers to study the beneficial effects of hypothermia for decades. Today, therapeutic hypothermia is used frequently in areas such as post cardiac arrest, myocardial infarction, stroke, traumatic brain injury, and perinatal asphyxia. However, the optimal cooling method and overall effectiveness of temperature management in the critical care setting remains controversial.

During the 11th International Consensus Conference in Intensive Care Medicine, Therapeutic Hypothermia – To Cool or Not To Cool?, a panel of experts will examine current practices and research in therapeutic hypothermia and temperature management during an informed debate. Topics to be covered include:

• Effectiveness of various cooling techniques
• Management of patients with fever and abnormalities using temperature control
• Effects of hypothermia on drug metabolism, coagulation and infection
• Optimal methods for rewarming patients

The 11th International Consensus Conference will be held at the Condado Plaza Hotel and Casino in San Juan, Puerto Rico, April 23 and 24, 2009. Registration opens in October 2008. For more information, click here.

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NIH Critical Care Research Group Plans Inaugural Meeting

The inaugural meeting of the National Institutes of Health (NIH) U.S. Critical Illness and Injury Trials Group (USCIITG) will be held November 18 and 19. The meeting will be held in conjunction with the 6th Symposium on the Functional Genomics of Critical Illness and Injury, to be held November 17, 2008.

USCIITG, a group funded by the National Institute of General Medical Sciences to create a clinical research framework that will reduce the barriers to investigation using the same investigator-initiated, evidence-driven, inclusive approach that has proven successful elsewhere, will meet to discuss a strategic plan for critical illness and injury clinical research. Investigators from various critical illness and injury specialties will be involved in this collaborative effort, which will aim to:

• Establish an inclusive, nationwide network of experts to review published data, establish national priorities, vet hypotheses, write clinical protocols and generate pilot data.
• Promote interactions and synergy across established programs -- both academic and non-academic -- to improve the robustness of clinical trials and to test hypotheses in U.S. populations across the patient age continuum.
• Provide a venue to discuss education and training in the science of clinical trial design, including conduct, analysis and reporting for critically ill or injured patients.
• Ensure patient protection and privacy by addressing the ethical, legal and social implications of research in the specialized circumstance of critical illness or injury.

In addition, the Symposium on the Functional Genomics of Critical Illness and Injury will featured scientific sessions addressing epigenetics and stress, new technology and applications, and phenomics.

Click here for more information on these meetings.

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Deadlines Approaching for Awards and Grants

Do you know a Society of Critical Care Medicine (SCCM) member whose dedication and commitment to multiprofessional critical care deserves to be recognized? Are you seen as an example of teaching excellence at your institution? Has your intensive care unit (ICU) recently been redesigned or adopted a new family-centered policy? If so, now is the time to apply for or nominate colleagues for one of SCCM’s many awards.

Apply by August 15, 2008
ICU Design Citation Award – Intensive care units designed with attention to functional and humanitarian issues may be eligible for this award.

Apply by September 1, 2008
Dr. Joseph and Rae Brown Award – Nominate an SCCM member who has significantly advanced multiprofessional quality care at the regional or local level.

Grenvik Family Award for Ethics – Recognize an SCCM member who has made significant contributions toward addressing ethical problems in critical care.

Norma J. Shoemaker Award for Critical Care Nursing Excellence –Recognize an SCCM nurse member who demonstrates excellence in clinical practice, education and/or administration in the field of critical care.

Family-Centered Care Award – Nominate an ICU team that has made an extra effort to improve the care of patients and their families. This award recognizes efforts to move family-centered care forward and to raise standards.

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Critical Care Medicine: Editor's Picks:

Log into MySCCM.org to access Critical Care Medicine online. Check out these choice features from journal editor, Joseph Parrillo, MD, FCCM.

August Critical Care Medicine Features:

• Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients.  Abstract
• The association between nighttime transfer from the intensive care unit and patient outcome.  Abstract
• Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Abstract

Join SCCM today to receive full access to Critical Care Medicine.

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