Monday, August 20, 2007

Medicare - Medicare Will No Pay for Hospital Errors

An Aug. 19 NYT article “Medicare Says It Won’t Cover Hospital Errors.” says Medicare won’t pay for conditions “that could reasonably have been prevented.”

These preventable conditions, sometimes dubbed “never events,” i.e. events that should never have happened, may include:

• Bedsores or pressure ulcers not present on admission.
• Injuries caused by falls
• Infections caused by catheters left in blood vessels or bladders
• Sponges or other objects left in patients during surgery
• Incompatible blood transfusions
• Death from other blood products
• Misuse or malfunction of medical devices
• Wrong site surgeries.
• Restraint strangulation.
• Deaths from medications.
• Deaths from childbirth.

The list is probably longer, but we won’t know until Medicare publishes its final rules next week. Medicare’s move is designed to save lives and $400 million from bad things that can happen to good people that could have been prevented.

Like all rules and regulations emanating from the top-down these rules have intended and desirable consequences.

• Reduction of hospital-acquired infection through gowning, hand washing, and discarding of items used on infected patients.
• Systematic steps to reduce hospital injuries
• Careful inspection and screening of patients on admission to check for pre-existing problems.
• Alerting patients to dangers lurking in hospitals
• Decline in medication errors
• Cessation of “never” errors
• Saving money for Medicare
• Enhanced patient safety

But there may be unintended consequences, as well. These include, in no particular order.

• New opportunities for the nation’s malpractice attorneys. .
• Heightened expectation among patients that their hospital admission will have good results, and if not, why not.
• Hospitals absorbing new costs for unexpected complications.
• New expenses for hospitals in the form of laboratory tests to check for staph infections by nasal swabs for every patient and preadmission testing for urinary tract infections
• The reporting of every adverse event by hospitals.

On balance, these new rules are a good thing. They culminate a series of converging events. :

• The Institute of Medicine’s 1999 report To Err is Human
• the 2005 The Institute of Healthcare Improvement campaign on saving 100,000 lives in hospitals
• Kenneth Kizer’s diligent work at the National Quality Forum and the VA
• active engagement and education of patients of patients through online programs as to what expect from surgical procedures before admission
• the movement among safety advocates that payers should never reward hospitals for “never events,” i.e. events that should never have occurred
• the Geisinger Clinic’s recent report that it will pay for complications occurring 90 days after CABG surgery.

Will these rules protect seriously ill patients, many at the end of life and many immunologically compromised, against all dangers even if they receive scrupulously correct care? Probably not. Nothing in medicine is absolute, including patient safety, but they’re a start.


Dino William Ramzi said...

I have posted a link to your blog from mine.

Frankly, I have expressed concern that the data we have now is not yet actionable and a complete refusal to pay is unlikely to improve quality.

When I reread the proposed rule it does not seem that CMS is not just adjusting rates, it is plain refusing to pay for the entire complication. This can only be justified by pressure to balance the budget.

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