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Medicare Will Not Pay For Preventable Conditions Acquired At Hospitals

Armen Hareyan's picture

Medicare no longer will reimburse hospitals for the treatment ofpreventable errors, injuries and infections that occur in thefacilities under a new rule scheduled for publication this week, a movethat CMS officials said could save lives and millions of dollars, the New York Timesreports. Under the rule, Medicare no longer will reimburse hospitalsfor the treatment of certain "conditions that could reasonably havebeen prevented," and the facilities "cannot bill the beneficiary forany charges associated with the hospital-acquired complication" (Pear, New York Times, 8/19).

Theeight conditions for which Medicare no longer will reimburse hospitalsfor treatment include: falls; mediastinitis, an infection that candevelop after heart surgery; urinary tract infections that result fromimproper use of catheters; pressure ulcers; and vascular infectionsthat result from improper use of catheters. In addition, the conditionsinclude three "never events": objects left in the body during surgery,air embolisms and blood incompatibility (USA Today, 8/20).

Therule, proposed by CMS in April and mandated by a 2005 law, will takeeffect in October 2008. CMS officials said that next year they plan toadd three additional conditions to the list (Zhang, Wall Street Journal, 8/20).


CMS spokesperson Jeff Nelligan said, "Our efforts in this arena and inother payment rules are to ensure that CMS is an active purchaser, notpassive payer, of health care." Nelligan added that the new rule"underscores our drive toward quality, efficiency and integrity in thehospital setting." Herb Kuhn, acting CMS deputy commissioner, said,"Medicare payments for inpatient services will be more accurate andbetter reflect the severity of the patient's condition" (AP/Houston Chronicle, 8/18).

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Lisa McGiffert, a health care policy analyst at Consumers Union,said, "Hundreds of thousands of people suffer needlessly frompreventable hospital infections and medical errors every year."McGiffert added, "Medicare is using its clout to improve care and keeppatients safe. It's forcing hospitals to face this problem in a waythey 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 requirethe reporting of health care events that everyone agrees should neverhappen," adding, "Any such effort must include a mechanism to make surehospitals comply."

Implications for Hospitals

The new rule "raises the possibility of changes in medical practice asdoctors hew more closely to clinical guidelines and hospitals performmore tests to assess the condition of patients at the time ofadmission," according to the Times. Most states do notrequire hospital records to indicate whether patients developconditions before or after admission, according to Nancy Foster, a vicepresident of the American Hospital Association.According to Foster, the rule will require hospitals to conductadditional tests to prove that Medicare beneficiaries developedconditions before admission to ensure reimbursement.

Hospitalofficials "worry that they will have to absorb the costs of these extratests because Medicare generally pays a flat fee for each case," the Timesreports. In addition, Foster said that some of the conditions on thelist of those for which no longer will reimburse hospitals fortreatment are not preventable in all cases. Tammy Lundstrom, chiefmedical 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).

Reprinted with permission from kaisernetwork.org. Youcan view the entire Kaiser DailyHealth Policy Report, search the archives, and sign up for email deliveryat kaisernetwork.org/email. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, afree service of The Henry J. Kaiser Family Foundation.