December 1, 2008
Run a Google search on “never events” + hospital + Medicare and you will find about 15,700 results. Among the most recent are articles on the new Medicare regulations that limit-payments to hospitals for treating patients for events that should never have occurred – the Hospital Acquired Conditions (HAC) regulations.
Starting on October 1st of this year, hospitals will no longer receive a higher payment for certain cases having a secondary diagnosis for a condition that (1) was not present on admission and (2) could reasonably have been prevented by following evidence-based guidelines.
For example, if a Medicare patient is admitted with a principal diagnosis of Intracranial hemorrhage or cerebral infarction (stroke) with MCC (Medical Severity adjusted Diagnosis-Related Group 066) and is discharged with a secondary diagnosis of Stage III pressure ulcer (ICD-9 code 707.23), the hospital’s payment will be less if the pressure ulcer was not documented using the correct Present On Admission (POA) indicator in the admission history.
Using 50th-percentile data, the average payment for MS- DRG 066 is $5,348. If the pressure ulcer were seen at the time of the patient’s admission and the correct diagnosis code were documented, the payment would go up to $8,030. On the other hand, if the ulcer was present but not observed and noted when the patient arrived at the hospital, or if it developed during the patient’s stay (POA code N, “Diagnosis was not present at time of admission” or POA Code U, “Documentation insufficient to determine if the condition was present at the time of inpatient admission”), there would be no additional payment of $2,682.
Some cynics have suggested that Medicare patients will now automatically be given a “never event” diagnosis such as pressure ulcers or “Dislocation of patella-open due to a fall” (ICD-9 836.4) upon admission. Others have said that hospitals will attempt to turf high-acuity patients or at least avoid performing procedures on them.
It is hard to disagree with J. James Rohack, MD, President-Elect of the American Medical Association, when he takes issue with what he aptly calls a “pay for perfection” system. Many of the 10 categories of HACs on Medicare’s “never” list are events that could well occur even if the whole surgical team adhered, for instance, to the best evidence-based infection-prevention protocols.
The 10 Medicare categories of HACs include:
- Foreign Object Retained After Surgery
- Air Embolism
- Blood Incompatibility
- Stage III and IV Pressure Ulcers
- Falls and Trauma
- Fractures
- Dislocations
- Intracranial Injuries
- Crushing Injuries
- Burns
- Electric Shock
- Manifestations of Poor Glycemic Control
- Diabetic Ketoacidosis
- Nonketotic Hyperosmolar Coma
- Hypoglycemic Coma
- Secondary Diabetes with Ketoacidosis
- Secondary Diabetes with Hyperosmolarity
- Catheter-Associated Urinary Tract Infection (UTI)
- Vascular Catheter-Associated Infection
- Surgical Site Infection Following:
- Coronary Artery Bypass Graft (CABG) - Mediastinitis
- Bariatric Surgery
- Laparoscopic Gastric Bypass
- Gastroenterostomy
- Laparoscopic Gastric Restrictive Surgery
- Orthopedic Procedures
- Spine
- Neck
- Shoulder
- Elbow
- Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
- Total Knee Replacement
- Hip Replacement
Clearly quite a few of the HACs on this list are ones in whose prevention anesthesiologists are involved. The private, not-for-profit standards-setting organization National Quality Forum has a longer list with 28 never events. Medicare intends to add more HACs to those for which it already penalizes hospitals. Anesthesiologists will likely be called upon to help reduce the rates of occurrence of a number of these mishaps.
Although only hospital payment is affected to date – and the amount of total savings is small in health care terms, the government estimating that some $21 million would be saved annually by not paying for 500,000 follow-up procedures to correct complications from the hospital preventable errors -- few doubt that physicians will share in the provider experience sooner or later. Indeed, about 20 states have never-event statutes on the books already.
The recent implementation of the HAC regulations strengthens ABC’s view that our clients should be seeking out ways to partner with their hospitals in meeting the challenges of making health care safer. To put it bluntly, anesthesiologists will be at the table – or they will be on the menu. We encourage clients to work with their hospitals to improve quality and to work with their practice management teams to strengthen continuously their relationships with their hospitals.
If you have questions or concerns about the never-event program, ABC will be pleased to help our current and future clients. Please visit http://www.cms.hhs.gov/HospitalAcqCond and/or contact info@anesthesiallc.com. Note that the Centers for Medicare and Medicaid Services (CMS) will hold a “listening session” on the Hospital-Acquired Conditions and Hospital Outpatient Healthcare-Associated Conditions on Thursday, December 18, 2008. Details of this session will be posted at http://www.cms.hhs.gov/HospitalAcqCond/07_EducationalResources.asp Specific questions about the HAC regulations should be directed to Karin Bierstein, JD, MPH, Vice President for Strategic Planning and Practice Affairs.
