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Medicare to Stop Paying for Hospital Errors
BY MARY ELLEN SCHNEIDER
In a continuing effort to link payments to quality, Medicare will soon stop paying hospitals for certain conditions and infections that are acquired by patients after admission.
The change was mandated by Congress under the Deficit Reduction Act and will go into effect in October 2008. Starting this October, hospitals will be required to report on secondary diagnoses that are present at the time of admission.
Officials at the Centers for Medicare and Medicaid Services have identified eight "reasonably preventable" events that can be avoided in most cases by engaging in good medical practice.
Hospitals will not receive additional payments for these secondary diagnoses if they develop after admission:
- An object left in the patient during surgery
- Air embolism
- Blood incompatibility
- Catheter-associated urinary tract infections
- Falls
- Pressure ulcers
- Vascular catheter-associated infections
- Mediastinitis after coronary artery bypass graft surgery
- CMS officials will consider adding three other hospital-acquired conditions next year
- Ventilator-associated pneumonia
- Staphylococcus aureus septicemia
- Deep vein thrombosis/pulmonary embolism
Under the new policy, the costs cannot be passed along to patients. However, hospitals will not bear the total financial risk of these cases because the payment policy will not affect Medicare's high-cost outlier policy.
CMS will continue to use the hospital's total charges for all inpatient services provided during a patient's stay when determining whether the case qualifies for an outlier payment.
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THE CMS POLICY SENDS A ‘LOUD AND CLEAR SIGNAL’ TO HOSPITALS THAT THEY MUST PAY ATTENTION TO THESE PREVENTABLE EVENTS. |
The move was applauded by payers and quality advocates, but hospitals and physicians raised some red flags about the change.
In a June 12 letter to CMS, the American Medical Association voiced concerns that the policy could have "significant unintended consequences for patients."
"The concept of not paying for complications that are often a biological inevitability regardless of safe practice is discriminatory and could be punitive to those patients at the greatest risk," wrote Dr. Michael D. Maves, executive vice president and CEO of the AMA.
"Certain patients, including those that are older, have medical comorbidities, or have otherwise compromised immune systems, are more susceptible to infection and other complications."
These types of patients already have difficulty accessing care, and the CMS policy could increase the barriers, Dr. Maves wrote.
Although the CMS focus on quality and patient safety is laudable, agency officials are overreaching with their list of conditions, said Dr. Junaid Khan, a cardiothoracic surgeon in Oakland, Calif.
For example, surgical site infections are a significant problem, but it's unlikely that they can be eliminated even with proper adherence to guidelines, he said, adding that a more global approach would be more useful at identifying systems issues and improving patient safety.
The devil is likely to be in the details, said Dr. Jeffrey Milliken, a cardiothoracic surgeon at the University of California, Irvine. The nature of the underlying disease and whether clinical guidelines were followed must be considered in order for the policy to be fair and effective.
The American Hospital Association supports the inclusion of only three of the conditions outlined by CMS (an object left in during surgery, air embolism, and blood incompatibility). However, there are concerns about whether the other conditions are always or even usually preventable, even with excellent care, according to David Allen, who is an AHA spokesperson.
Preexisting conditions also are of concern. For example, if a person presents to the emergency department with shortness of breath, the physician may not test for a urinary tract infection, he said.
But the Medicare policy shift was welcomed by health plans and some quality advocates.
The announcement by CMS is consistent with the move to pay for quality, said Susan Pisano, a spokesperson for America's Health Insurance Plans. The new policy provides an incentive for hospitals to develop processes to avoid these conditions, she said.
Officials at the National Committee for Quality Assurance (NCQA) also favor the policy change. "If we can't say no to the wrong kinds of care, it going to be virtually impossible to say yes to the right kinds," said Jeff Van Ness, a spokesman for NCQA.
The CMS policy sends a "loud and clear signal" to hospitals that they must pay attention to these preventable events, said Rachel Weissburg, a program associate at the Leapfrog Group, a coalition of employers focused on health care quality and transparency.
In fact, officials at the Leapfrog Group would like to see CMS expand the list of hospital-acquired conditions to include the 28 serious reportable events--rare medical errors that should never happen to a patient--which have been compiled by the National Quality Forum.
The Leapfrog Group launched a project last year to encourage hospitals to develop plans to avoid these serious reportable events.
In its 2007 Quality and Safety Survey, the group offered hospitals public recognition if they agreed to take four actions following a serious reportable event: offer an apology to the patient or family, report the event to a recognized reporting agency, perform a root-cause analysis, and waive all costs directly related to the event.
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