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Medicare News
Medicare Will Not Pay for Preventable Conditions
Acquired at Hospitals
Most notable are infections; insurance companies
may follow suit
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Eileen ONeill-Pardos mother, Margaret, died after
an infection developed at a hospital. Photo by Stuart Isett for The New
York Times |
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Aug. 20, 2007 - 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."
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The
Centers for Disease
Control and Prevention estimates that patients develop 1.7
million infections in hospitals each year, and it says those infections
cause or contribute to the death of 99,000 people a year about 270 a
day. |
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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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