Pneumonia, antibiotics, and CMS

This is the text of an email I got from one of my professional societies, AAEM.  I’m copying it here, and highlighting some of the text, to support a minor rant to follow:

AAEM Update from Dr. William Rogers of CMS (speaker at the 2005 Scientific Assembly):

Thanks to AAEM for inviting me to speak at the annual meeting. The dialog was valuable to me and I am committed to helping enforce the CMS requirement that physicians have access to information concerning billing for services they render. I must apologize for a HUGE mistake I made in responding to a question concerning "four hours to administer antibiotics for pneumonia." I said that CMS was not going to define a time period within which antibiotics must be administered to patients with pneumonia in our hospital quality measures and I was wrong. We have defined the acceptable time period as four hours. These measures will change over time and I am well aware of the challenge that many EDs will have in meeting this target. To the extent that the target encourages hospitals to make investments which will reduce waiting times and allow for more timely treatment; the goal will be serving a useful purpose. I am concerned that some overwhelmed emergency departments will resort to creative strategies to improve their scores which won’t really improve the quality of care; an approach which should not be encouraged. If the Physicians Regulatory Issues Team at CMS can be of help to the AAEM in any way, please call or email us.

William D Rogers, MD FACEP
Medical Officer, Office of the Administrator Director, Physicians Regulatory Issues Team Center for Medicare and Medicaid Services

The bold text has to do with getting antibiotics into patients with pneumonia within four hours of diagnosis of said pneumonia.  Sounds easy, right?  Well, the patient is seen, and the clock starts (I think, please correct me if the clock starts elsewhere).  It takes time for the xray order to get entered, for the patient to get an xray, for the doctor to be aware the xray has been taken, the xray to be seen by a doctor, find the chart, write an order for antibiotic, nurse gets chart, gets antibiotic, and starts it.  In a perfect world that’d take 30 minutes, tops.  I don’t know any ER doc who works in a perfect world.

The underlined text is what burns me up right now.  Deadlines can make hospitals make investments, but since CMS has decided to use the WalMart version of financial management, ie, pay a little less every year, where will this money come from?  Yes, we’re going to be forced to be ‘creative’ in the face of losing medicare funding.

Medicare (CMS) has the authority to withhold money if their goals aren’t met, so there’s a lot of emphasis on meeting the target.  However, eventually medicare payments will get low enough it won’t be wort the effort.

And that’s when the fun starts in healthcare financing.


  1. At our facility, the clock starts *at admission*. That means that (since we don’t have a formal ED) there can be a wait of an hour or more for a bed, on top of the waiting times for X-rays, VQs, etc.

    I had a patient come in yesterday, in fact, with a preliminary diagnosis of pneumonia. It wasn’t until we’d run a bag of antibiotics and done umpteen things to comply with JCAHO standards that she got a VQ scan and we found the PE that had caused her chest pain and shortness of breath.

    Makes me wonder how much money we charged her insurance company and how much time we wasted before we got a proper diagnosis.

  2. A groaning sound, a crack here and there, a sifting of plaster . . . and the building collapses.

  3. At what point will hospitals be forced to move to a “stabilize and transport” mode of operation in order to minimize losses due to medicare entanglements?

  4. Aah, William, now you’re talking.

    Get loose from Medicare, and a huge amount of paperwork would be minimized, if not eliminated. All the JACHO mandated feel-good sillyness (dietary assessments in the ED, pain scales for everyone) would no longer be enforced, because JACHO would no longer hold the Big Stick. Not that those two examples are huge paperwork issues, they’re just top of the mind silly things we’re forced to do for everyone to keep JACHO accreditation, and therefore Medicare money.

    EMTALA, the biggest unfunded mandate in healthcare, would stop in hospitals that no longer accepted medicare. Stabilize and transport to a medicare-participating hospital.

    Some good would come of it: we could actually talk about cost and prices with our patients, making them better consumers of healthcare. I remain convinced the reason costs continue to climb is that the incured/covered patient is divorced from actual cost.

    So, that’s what I’m wondering, too. Where’s the breakpoint where it’s no longer worth the hassel to accept Uncle’s increasingly meager reimbursements?

  5. I agree with Joe, at our site the clock starts when the patient walks through the door. During the busy winter season, the patient has already been in the ED 1-3 hours before being seen by the doc. If the 30% plus cuts that CMS has planned for us in the next 5 years occur then the breaking point is short on the horizon, if not already upon us.

  6. It will take maybe two county hospitals almost anywhere in the US to start refusing Medicare to create the kind of furor that will cause CMS to back down. When word gets out that cuts are affecting access to Medicare patients in hospitals, there will be significant blowback. Cuts to Part II don’t get that much interest, but failure of Part I is a whole other story.

  7. Our clock starts at the time of ED registration – (on the other hand, for their inpatients doctors have 4 hours from the time they write the diagnosis).

    We have also been getting ‘dinged’ for not doing cultures. Apparently you are not required by CMS to do cultures (unless they go to the unit?), but if you do them they have to be done BEFORE antibiotics. And it seems that most of our medical staff is anti-EBM and wants cultures on EVERYONE. The brilliant solution is to get cultures and give antibiotics to EVERYONE with a cough…very cost efficient.

    There was also some discussion of decreasing the time to 2 hours…

  8. GruntDoc says:

    Our “Parent” organization, in an effort to maybe help healthcare but mostly to show ‘quality improvement measures that can be measured’ want blood cultures on 100% of patients with an admitting diagnosis of pneumonia. We have argued against this without success.

  9. I have had another idea.

    If CMS pays, say, 40% of the billed charges, we should be willing to meet their targets 40% of the time.

    Just a thought.


  1. symtym says:

    Four Hour Rule

    GruntDoc reviews an email we both received today from AAEM and I couldn't agree more. What I'm concerned about is the failure of the hospitals to understand that it is a system problem (the majority of the time having nothing to do with the p…