CMS Proposal Says Medicare Won't Pay Hospitals for
Mistakes Like Cutting Off Wrong Leg
Adding 43 new quality measures on which hospitals
have to report data in order to receive full payment for services
April
15, 2008 - The screws are being significantly tightened to improve the
care of Medicare patients in the hospital and to save millions of
dollars for Medicare by not paying for certain conditions - such as
having the wrong leg cut off - that are caused in the hospital. The
Centers for Medicare & Medicaid Services (CMS) on Monday proposed these
additional steps to strengthen this tie between the quality of care
provided to Medicare beneficiaries and payment for the services.
Beginning October 1, 2008, Medicare will no longer
pay hospitals at a higher rate for the increased costs of care that
result when a patient is harmed by one of several conditions they didnt
have when they were first admitted to the hospital and that have been
determined to be reasonably preventable by following generally accepted
guidelines.
The proposed rule also updates Medicare payment
rates and policies for inpatient hospitals for FY 2009, which CMS
estimates will increase Medicare payments to acute care hospitals by
nearly $4.0 billion.
CMS is proposing to expand the list of conditions
which it has determined are "reasonably preventable through proper care"
and for which Medicare will no longer pay at a higher rate if the
patient acquires them during a hospital stay.
In addition, CMS is adding 43 new quality measures
for which hospitals will have to report data in order to receive the
full annual payment update for their services.
CMS is taking aggressive actions to ensure that
beneficiaries get safe, high quality, and efficient care from their
health care providers, and the actions we are announcing today build on
our efforts, said CMS Acting Administrator Kerry Weems.
The status of the Medicare Hospital Insurance
Trust Fund requires us to find the best solutions to ensure that
Medicare stays strong while paying providers appropriately for the care
they deliver. The reforms we are proposing in this rule should lead to
greater value for Medicare beneficiaries and the Medicare program.
"The proposed regulation builds on efforts across
Medicare to transform the program to a prudent purchaser of health care
services, paying based on quality of care, not just quantity of
services," according to the announcement.
CMS is also making hospital quality and cost
information available to help consumers make more informed choices. On
March 28, CMS posted updated pricing and quality information at
www.hospitalcompare.hhs.gov, along with the results of surveys of
patients about their experience with the care they received while in the
hospital.
The proposed rule would apply to services provided
to patients who are discharged from the hospital during fiscal year (FY)
2009, which begins on October 1, 2008.
The agency says numerous studies have documented
the detrimental effects on patients and their loved ones and the
increased costs of health care services resulting from a preventable
patients injury or condition acquired due to hospital errors. These
can include Never Events, those events that never should occur, like
amputation of the wrong limb or transfusing patients with the wrong
blood type.
CMS is working with the National Quality Forum (NQF),
a national organization working to promote patient safety and improve
hospital care, on ways to reduce or eliminate 28 Never Events identified
by NQF.
In its 1999 report, To Err is Human: Building a
Safer Health System, the Institute of Medicine (IOM) concluded that
medical errors, particularly hospital-acquired conditions (HACs), may be
responsible for as many as 98,000 deaths annually, at costs of up to $29
billion.
In 2000, the Centers for Disease Control and
Prevention (CDC), estimated that hospital-acquired infections added
nearly $5 billion to hospital costs. At the same time, a 2007 survey by
the Leapfrog Group of more than 1,200 hospitals found that 87 percent
did not follow recommendations to prevent many of the most common
hospital-acquired conditions.
When these conditions occur during a hospital
stay, the patient and his or her family suffer needlessly. To make
matters worse, these conditions are likely to result in higher medical
bills for the family to pay for additional services for physician care,
prescription drugs, and other items and services that would not have
been necessary if proper care had been provided, said Weems.
Medicare can and should take the lead in
encouraging hospitals to improve the safety and quality of care and make
better practices a routine part of the care they provide not just to
people with Medicare, but to every patient they treat.
The rules proposed by CMS expand two key
initiatives that begin to link payments for health care services to
quality of care the Hospital-Acquired Conditions and the Hospital
Quality Measure Reporting initiatives.
Under the HAC initiative, beginning October 1,
2008, Medicare will no longer pay hospitals at a higher rate for the
increased costs of care that result when a patient is harmed by one of
several conditions they didnt have when they were first admitted to the
hospital and that have been determined to be reasonably preventable by
following generally accepted guidelines.
The HAC provisions in Medicare regulations required
hospitals to begin reporting on their Medicare claims on October 1,
2007, whether certain specified diagnoses were present when the patient
was admitted.
Last Year's List
The first eight conditions, which were selected
last year because they greatly complicate the treatment of the illness
or injury that caused the hospitalization, resulting in higher payments
to the hospital for the patients care by both Medicare and the patient,
were:
Object
inadvertently left in after surgery Air embolism
Blood
incompatibility Catheter
associated urinary tract infection Pressure ulcer
(decubitus ulcer) Vascular
catheter associated infection Surgical site
infection- Mediastinitis (infection in the chest) after coronary artery
bypass graft surgery Certain types
of falls and trauma
The New List
CMS is proposing to expand the list of conditions
that need to be reported if present when a patient is first admitted and
is seeking public comment on whether they should be added to the list in
the final rule to be announced later this year.
The list in the proposed rule includes:
Surgical site infections following certain elective procedures Legionnaires
disease (a type of pneumonia caused by a specific bacterium) Extreme blood
sugar derangement Iatrogenic
pneumothorax (collapse of the lung) Delirium
Ventilator-associated pneumonia Deep vein
thrombosis/Pulmonary Embolism (formation/movement of a blood clot) Staphylococcus
aureus septicemia (bloodstream infection) Clostridium
difficile associated disease (a bacterium that causes severe diarrhea
and more serious intestinal conditions such as colitis)
Beginning October 1, 2008, Medicare will no longer
pay the hospital at a higher rate for the original eight conditions or
any conditions added to the list in the final rule, if they were
acquired during the hospital stay.
Expansion of Reporting
The second initiative CMS is proposing is the
expansion of the hospital quality measure reporting program, which
reduces the amount a hospital is paid if it does not participate in the
voluntary reporting of standardized quality measures.
These are measures that are publicly reported on
Hospital Compare. Hospitals are currently required to report 30 quality
measures on their claims for Medicare inpatient services to qualify for
a full update to their FY 2009 payment rates. CMS is proposing to add
43 quality measures to the list in order to get the full inflation
update for FY 2010, bringing the total number of measures in FY 2009 to
73.
The proposed additions include the measures of the
following types:
Surgical Care Improvement Project (SCIP) 1 new measure Hospital
readmissions 3 Nursing care
4 Patient Safety
Indicators developed by the Agency for Healthcare Research and Quality (AHRQ)
5 Inpatient
Quality Indicators developed by the AHRQ 4 Venous
thromboembolism measures (VTEs) ‑ 6 Stroke measures
(STK) 5 Cardiac surgery
measures 15
In proposing to require hospitals to report on
readmissions, CMS notes that almost 18 percent of Medicare patients are
readmitted to the hospital within 30 days of discharge, potentially
exposing the patients and their families to significant additional
suffering.
Taken together with the patient satisfaction
information recently reported on Hospital Compare web site that shows
the effectiveness of nurse and physician communication with the patient,
including discharge planning, the building blocks for monitoring and
improving the entire episode of care will be available.
Cost to Taxpayers
The impact on taxpayers is also significant.
According to the Medicare Payment Advisory Commission (MedPAC),
readmissions cost the program $15 billion annually, with $12 billion of
those costs potentially preventable.
The proposed rule would apply to more than 3,500
acute care hospitals paid under the Inpatient Prospective Payment System
(IPPS). The IPPS was intended to reward hospitals for being efficient
by making a single payment to the hospital based on the average costs of
treating a patient with a particular diagnosis, rather than paying for
the actual costs of each case. However, until recently, Medicare did
not have the legal authority to use its payment system to encourage
hospitals to improve the quality of care they furnish.
Comments on the proposed rule will be accepted
through June 13. CMS will respond to comments in a final rule to be
issued on or before August 1, 2008.
April
15, 2008 - The screws are being significantly tightened to improve the
care of Medicare patients in the hospital and to save millions of
dollars for Medicare by not paying for certain conditions - such as
having the wrong leg cut off - that are caused in the hospital. The
Centers for Medicare & Medicaid Services (CMS) on Monday proposed these
additional steps to strengthen this tie between the quality of care
provided to Medicare beneficiaries and payment for the services.