Hospital executives are scrambling to prepare for a Medicare rule change regarding hospital-acquired infections that has the potential to cut into their revenue.
The CMS final rule on hospital payments under the inpatient prospective payment system for fiscal 2008 implemented a provision of the Deficit Reduction Act of 2005, which denies hospitals higher payment under Medicare for the additional costs of treating patients who acquire a condition (including an infection) during a hospital stay (Aug. 6, p. 8).
As a result, hospitals are working to bring their admission-reporting practices into compliance with the new Medicare provision that denies further payment to fix medical errors. Quality experts say the rule change will save patient lives.
Hospitals are expected to begin reporting secondary diagnoses that are present on patient admissions, beginning with discharges on or after Oct. 1. Starting in fiscal 2009, cases with these conditions will not be paid at a higher rate unless they were present on admission. Theres an assumption in the rule that coding can be implemented quickly to separate those patients who had an infection or pressure sore from the time of admission rather than acquiring it in the hospital, Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, said in an interview.
In all but two states, that kind of present on admission coding does not exist, and there is little time to put it in place effectively, Foster said.
To ensure that hospital payments arent affected under this new provision, administrators are going to have to start educating their clinicians on what they need to write in the medical record, to properly code infections on admission, Foster said.
This will take a significant investment of time and resources on behalf of the doctors and other staff, Foster said.
The rule identifies eight conditions that meet the statutory criteria under this new payment rule. These include: catheter-associated urinary tract infections, pressure ulcers, vascular catheter-associated infections, surgical-site infections and hospital-acquired injuries. The list also includes three serious preventable events or never events: object left in surgery, air embolism and blood incompatibility. All three are included in the National Quality Forums list of 28 serious reportable events in healthcare. In its final rule, the CMS also indicated it would add three new conditions to the list next year.
Foster said the AHA was surprised to see that the agency had expanded the list of conditions from six in the proposed rule to eight in the final. The two new ones include hospital injuries (inner cranial or crushing injuries, burns and falls) and surgical-site infections, which essentially just refers to one type of infection, where tissues in the central-chest area become infected during open-heart surgery, she said.
The problem with adding the new conditions after the comment period is the CMS didnt get the added benefit of clinical and other perspectives on those two issues, Foster said.
The new rule seems to represent yet another manifestation of CMS new philosophy: to use the power of the purse to try to create a business case for safety and quality, she said. Whether this is the most effective way to accomplish that goal is indeed a question to assess over the next two years as the policy takes effect, Foster said.
Quality experts said that regardless of the potential downside, a move in this direction is a positive one. Until recently, Medicare was more of a bank than an active participant in healthcare quality and safetypaying for care just because a hospital or doctor submitted a bill and paying equally whether care was stellar or shoddy, said Robert Wachter, a physician who is chief of the medical service at 574-bed UCSF Medical Center, San Francisco.
When coupled with transparency, pay-for-performance, and other methods to improve quality and safety, this new payment mandate will save lives, Wachter said. There is no reason that a hospital should be paid extra for the additional care required for a patient with a preventable hospital infection or other complication. So, I say bring it on.
Wachter conceded that the new provision may be unfair or have unexpected consequences at times. Hospitals will now spend an inordinate (and sometimes clinically inappropriate) amount of time and effort trying to document that problems were present on admission, sort of like Hertz looking over the car for dings before you drive off the lot. And there are plenty of hospital errors and complications that really are not preventable in todays healthcare world.
Nevertheless, Betsy McCaughey, chairman of the Committee to Reduce Infection Deaths, thought the CMS could have gone further to include more types of infections in its list of conditions. The agency left out methicillin-resistant Staphylococcus aureus, for example, because of its belief the disease isnt preventable in hospitals, but the truth is that screening and cleaning can prevent 90% of infections, McCaughey said.
Hospital executives are already working on the issue.
Were doing everything possible to make sure these eight (conditions) dont occur, said Thomas Royer, president and chief executive officer of Christus Health in Irving, Texas. Royer believes all of the conditions are 100% avoidable, and we have action and education plans to attempt to minimize them or eradicate them completely.