Changing the rules

Proponents say the proposal would provide a strong incentive for hospitals to improve patient care. But concerned dermatologists say it can be difficult to determine when these conditions actually were acquired.

Robert Norman, M.D., head of the International Society of Geriatric Dermatology, says halting coverage of these conditions would be like the HMOs not paying for biopsies unless a patient's lesion is malignant.

"The problem here is that there's no way to determine whether a patient acquired MRSA or pressure sores in the hospital, or if those conditions existed when they were admitted," he says.

Under the proposed regulations, Medicare would withhold payments to hospitals for care associated with treating certain urinary tract infections, S. aureus bloodstream infections and four other medical errors unrelated to infections - bed sores, objects left in patients' bodies, blood incompatibility and air embolism.

These six were selected due to the high volume of patients affected, the high cost of treating patients or both, and because they are largely preventable by following established guidelines, according to the CMS.

So who will pay for treatment of those conditions?

"We know that while hospitals are constantly assessing and improving quality of care, there is still more work to be done. Sharing information about mistakes and steps to prevent them among hospitals is important," a spokesman said in a prepared statement. "That's why we supported federal legislation to set up patient safety organizations and are eagerly awaiting rules to make that happen."

Flexibility needed

Dermatologists say flexibility is needed.

Thomas Waldinger, M.D., in Dearborn, Mich., operates a practice that sees about 90 percent geriatric dermatology patients, who primarily present with skin cancer. He says he has seen new patients in his office with pressure sores, before they ever entered the hospital.

On the other hand, Dr. Waldinger currently has a patient who presented with a rash one week after leaving the hospital, and the culture was positive for MRSA. The patient has a skin malignancy near the infection site, so the staph infection must be cleared before the cancer can be treated.

"I'm working with an infectious disease doctor now, because it is difficult to eradicate this, but clearly, it is important to clear the infection so I can proceed with skin cancer surgery," he says.

"If we don't treat these conditions, they get worse; staph can be transmitted to other people, and additional complications set in. Obviously, it's important to treat them."

That creates a difficult issue for dermatologists. Dr. Waldinger advocates both prevention and treatment.

"There's nothing better than preventing disease, and the government's guidelines for prevention of hospital-acquired conditions can be helpful," he says. "There is a difference, however, between having standards and not understanding that each individual patient is different. We need to have flexibility, and ultimately, we need to treat patients.