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AAMC Reporter: August 2008
CMS Releases Preventable Conditions Rules
On July 31, the Centers for Medicare and Medicaid
Services (CMS) announced that as of Oct. 1 it will not
pay for treatments connected with three kinds of conditions
or complications that it considers preventable
in a hospital setting.
In its original proposed rule, CMS had suggested nine conditions
as candidates for its Hospital-Acquired Conditions
(HAC) initiative, which was created to incentivize high-quality
patient care by eliminating Medicare payments to
hospitals for care that results from a patient contracting
specified conditions. However, CMS decided to include
only three of the conditions in its final rule after the physician
and hospital communities charged that many of the
conditions were not reasonably preventable.
"Some of these measures require additional work, but
the agency will come back to these and others each
year," said CMS Acting Administrator Kerry Weems,
according to news reports.
The three conditions that will no longer be covered by
Medicare are complications related to surgical site
infections following elective procedures, certain manifestations
of poor control of blood sugar levels, and deep
vein thrombosis or pulmonary embolism following total
knee replacement and hip replacement procedures.
The six other conditions or complications originally
proposed for do-not-pay classification are Legionnaires'
disease, iatrogenic pneumothorax, delirium, ventilator-associated pneumonia, staphylococcus aureus septicemia,
and clostridium difficile-associated disease.
The HAC initiative is part of a rapidly growing movement
among public and private health care payers to tie
payments to positive patient outcomes, and increase
hospital accountability for patient safety. CMS has been
attempting to take the lead in this movement through
various measures including the HAC initiative and other quality improvement measures. Physicians and
hospital leaders said they welcome opportunities to
improve quality, but had questioned whether all nine
originally proposed conditions were truly preventable.
"Aligning quality with payment is wise and long overdue
in the U.S. health care system," said Peter J. Pronovost,
M.D., Ph.D., a professor of medicine and medical director
of the Center for Innovation in Quality Patient Care
at Johns Hopkins University School of Medicine. "In
the current system, overuse is paid for and misuse is
often rewarded. We have to pay for what we achieve....
But if we put the CMS rule into practice as proposed,
then it wasn't going to achieve its goal. Some of these
conditions [were] preventable, but for many, that's
just not the case."
"It feels like they're picking on places, like teaching
hospitals, that do the kinds of risky surgeries and procedures
that others do not. Hopefully, we'll get that all figured
out over time."
—Gordon Alexander,
M.D., president, University of Minnesota Medical
Center, Fairview |
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According to a CMS spokesperson, all the conditions were
selected based on frequency, treatment cost, preventability,
and other factors. The CMS estimates that the cost savings
from the proposal will be relatively small—about $20
million, or a tiny fraction of the total Medicare budget—and the intention of the rule is to improve care quality, not
save money.
Because teaching hospitals treat many high-risk and
complex cases as well as transfers from other treatment
locations, hospital executives wonder if it may be
appropriate to account for these higher risks.
"It feels like they're picking on places, like teaching
hospitals, that do the kinds of risky surgeries and procedures
that others do not," said Gordon Alexander,
M.D., president of the University of Minnesota Medical
Center, Fairview. "Hopefully, we'll get that all figured
out over time."
Various health care and policy experts have been critical
of the government for a perceived lack of leadership in
implementing evidence-based practices, or methods of
care that integrate cutting-edge clinical and scientific
data. The HAC initiative could be an opportunity to
change that, officials said, by using the program to mandate
improved policies on issues such as sterilization
and care efficiency.
"A wiser policy would be not just whether you had deep
vein thrombosis," Pronovost said. "But rather if you had
it and didn't get the recommended therapies."
The CMS has already finalized another rule that will take
effect Oct. 1 and designates eight other preventable conditions.
Hospitals are working to update their coding and
treatment protocols to better track and prevent accidental
cases of leaving medical objects inside patients after
surgery, hospital-acquired urinary tract infections, central
line-associated bloodstream infections, administration
of incompatible blood products, air embolism,
patient falls, mediastinitis after cardiac surgery, and
pressure ulcers. Hospital leaders objected to several of
these conditions being termed preventable as well.
At the state level, Minnesota hospitals collectively agreed
in 2004 not to charge anyone if any of 27 agreed-upon
preventable conditions occur, so the new rules will have
little practical impact in that state. According to Alexander,
Minnesota hospitals have already learned the
best ways to adjust their practices.
"We have a new form we fill out that forces the caregiver
to make a purposeful decision on whether or not to bill,"
Alexander said. "Some of these conditions, such as pressure
ulcers, we're finding are sometimes present on
arrival, and not acquired inside the hospital. So we have
trained our coders to seek out evidence of whether something
was present before or truly hospital-acquired."
—By Scott Harris
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