Medicare no longer will reimburse hospitals for the treatment of preventable errors, injuries and infections that occur in the facilities under a new rule scheduled for publication this week, a move that CMS officials said could save lives and millions of dollars, the New York Times reports. Under the rule, Medicare no longer will reimburse hospitals for the treatment of certain "conditions that could reasonably have been prevented," and the facilities "cannot bill the beneficiary for any charges associated with the hospital-acquired complication" (Pear, New York Times, 8/19).
The eight conditions for which Medicare no longer will reimburse hospitals for treatment include: falls; mediastinitis, an infection that can develop after heart surgery; urinary tract infections that result from improper use of catheters; pressure ulcers; and vascular infections that result from improper use of catheters. In addition, the conditions include three "never events": objects left in the body during surgery, air embolisms and blood incompatibility (USA Today, 8/20).
The rule, proposed by CMS in April and mandated by a 2005 law, will take effect in October 2008. CMS officials said that next year they plan to add three additional conditions to the list (Zhang, Wall Street Journal, 8/20).
Comments
CMS spokesperson Jeff Nelligan said, "Our efforts in this arena and in other payment rules are to ensure that CMS is an active purchaser, not passive payer, of health care." Nelligan added that the new rule "underscores our drive toward quality, efficiency and integrity in the hospital setting." Herb Kuhn, acting CMS deputy commissioner, said, "Medicare payments for inpatient services will be more accurate and better reflect the severity of the patient's condition" (AP/Houston Chronicle, 8/18).
Lisa McGiffert, a health care policy analyst at Consumers Union, said, "Hundreds of thousands of people suffer needlessly from preventable hospital infections and medical errors every year." McGiffert added, "Medicare is using its clout to improve care and keep patients safe. It's forcing hospitals to face this problem in a way they never have before."
Kenneth Kizer, a patient safety expert and former undersecretary for health at the Department of Veterans Affairs, said that the rules "should be part of a larger initiative to require the reporting of health care events that everyone agrees should never happen," adding, "Any such effort must include a mechanism to make sure hospitals comply."
Implications for Hospitals
The new rule "raises the possibility of changes in medical practice as doctors hew more closely to clinical guidelines and hospitals perform more tests to assess the condition of patients at the time of admission," according to the Times. Most states do not require hospital records to indicate whether patients develop conditions before or after admission, according to Nancy Foster, a vice president of the American Hospital Association. According to Foster, the rule will require hospitals to conduct additional tests to prove that Medicare beneficiaries developed conditions before admission to ensure reimbursement.
Hospital officials "worry that they will have to absorb the costs of these extra tests because Medicare generally pays a flat fee for each case," the Times reports. In addition, Foster said that some of the conditions on the list of those for which no longer will reimburse hospitals for treatment are not preventable in all cases. Tammy Lundstrom, chief medical officer at Providence Hospital in Michigan, said, "Serious, costly infections can occur even when doctors and nurses take all the recommended precautions."
The rule also might prompt private health insurers to implement similar policies. Susan Pisano, spokesperson for America's Health Insurance Plans, said, "Private insurers will take a close look at what Medicare is doing, with an eye to adopting similar policies" (New York Times, 8/19).
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