New Demonstration Project Proposed for CMS by Fringe Medical Group

(We hope you enjoyed our April Fool's jokes this year. Look for more of our past April Fool's posts here. - Ed.)

by Abe R Feaulx, Pallimed Special Reporter

Today the Center Opposing Medical Ethics Or Normalcy offered their proposal for a new demonstration project for the Centers for Medicare and Medicaid Services.  The demonstration project (if accepted)  will be requiring all Medicare participants' primary care physicians to certify that their patients will have a prognosis of 6 months or more in order to continue to receive curative care. A representative of COME-ON, who spoke to the national press on conditions of anonymity stated these measures "sound crazy but look what we imposed on hospice and this may keep those who are really sick from screwing the system."

Primary care physicians have initially responded with outrage stating that prognostication is an inexact science and that these requirements would be onerous and unfair to patients, but these concerns have largely gone without response. The same source was quoted as stating, "We all want excellent health care for ourselves and our families, but we want to make sure that we aren't paying for all those other people. This is the next step to ensure that our tax dollars are well spent."

This requirement is being considered after a small pilot project showed an 98% reduction in costs. In the pilot, only 0.3% of beneficiaries were deemed eligible for curative care. In order to qualify for curative care, a physician must demonstrate that the patient does NOT have a chronic or terminal illness and will live for at least six months. The physician must account for potentially unforeseen events. Upon review of claim denials, the most commonly seen reasons for denial were:

• “It is not clearly demonstrated that the patient is not at risk for electrocution from a lightning strike. This remains a risk factor for death in the next six months.”
• “It is not clearly demonstrated that this patient will not be a victim of a terrorist attack. The Homeland Security Advisory System level is yellow indicating an elevated risk of terrorist attacks. This remains a risk factor for death in the next six months.” 
• "It is not clearly demonstrated that this patient will not aspirate on popcorn while watching a movie with his children. This remains a risk factor for death in the next six months."
• "It is not clearly demonstrated that this patient will not have a stroke or fatal seizure while listening to "Friday" by Rebeca Black This remains a risk factor for death in the next six months."

The pilot received mixed reviews from  beneficiaries. Farmer Willie Simpson indicated that he was pleased with services that he received for his coronary artery disease and diabetes until he required a hospitalization for chest pain. “When I arrived at the hospital, I received notification from the social worker that my claim for the hospitalization would be denied because the ambulance ride placed me at risk for a fatal motor vehicle accident. I don’t know how else I would have come into the hospital, though. My farm is 30 miles outside of town and I don't own a car.” He received a $20,000 bill in the mail the following week.

The CMS requirement that hospice providers see patients every two months to certify that those who live more than 6 months are, in fact, still dying, is still in effect.