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More conditions may land on the no-pay list

June 2008

Published in the June 2008 issue of Today’s Hospitalist

Medicare adds nine conditions to its “no-pay” list

MEDICARE HAS PROPOSED adding nine new conditions to its list of patient complications that it will refuse to pay hospitals for next year.

The new conditions that the CMS has proposed withholding payment for include surgical site infections after procedures that include total knee replacement, Legionnaire’s disease, delirium and ventilator-associated pneumonia, DVT or PE, and diseases associated with C. difficile.

Last year, the Centers for Medicare and Medicaid Services (CMS) announced that as of October 2008, it would stop paying hospitals for eight conditions that it says are preventable. That list includes conditions like pressure ulcers and select hospital-acquired infections, as well as complications resulting from patient falls.

If patients have any of those conditions, Medicare will still pay for the hospitalized care of the patient, but not the “complicating condition.” Hospitals would be paid for complications on the no-pay list only if providers documented that those conditions were present on admission.

Patient safety advocates applauded the proposed additions, saying there is solid evidence that the conditions can be prevented. Others worry that with the newest additions to its no-pay list, Medicare is going beyond conditions that the medical literature has shown can definitively be prevented.

Some critics have also said that the CMS should monitor how smoothly its first iteration of the no-pay list is rolled out before adding new conditions.

Hip and knee replacements surged between 1997 and 2004

THE NUMBER OF HIP AND KNEE REPLACEMENT SURGERIES is rising dramatically, reflecting the aging of the U.S. population.

Between 1997 and 2004, the number of primary hip replacements jumped 48%, from 153,000 to nearly 226,000. During those same years, the number of first-time knee replacements rose 63%, from 264,000 to 431,000.

Those data were published in the April 15 Arthritis Care & Research by researchers from Florida International University in Miami. The authors predict that if those trends continue, there will be 600,000 hip replacements and 1.4 million knee replacements performed in 2015.

Researchers found that patients between the ages of 45 and 64 accounted for a growing portion of these surgeries. In 1997, this group accounted for 27% of first-time hip replacements and 26% of first-time knee replacements. In 2004, these patients accounted for 36% of both procedures.

Researchers also concluded that joint replacement surgeries cost about $9 billion in 2004. About half of that amount was paid by Medicare.

Survey says preventable errors affect 3% of Medicare patients

A NEW SURVEY ON PATIENT SAFETY found that during the years 2004-06, almost 240,000 Medicare patients died from errors that could have been prevented.

The fifth annual Patient Safety in American Hospitals Study found that the error rate for Medicare patients was 3%. When applied to the overall Medicare population, that translates into about 1.1 million patient safety incidents during the three years covered by the survey.

The survey was released in April by Health Grades, an organization that ranks the performance of health care organizations. Researchers compiled data by analyzing 41 million Medicare patient records.

When the survey examined the rate of medical errors at hospitals that Health Grades has deemed top performers, researchers found that patients at those facilities were 43% less likely to experience an error.

The survey also uncovered the following information about medical errors among Medicare patients:

● Patients who experienced a patient safety problem had a 20% chance of dying as a result of the incident.
● The overall death rate of patients on the receiving end of an error dropped about 5% between 2004 and 2006.
● During the study period, there were increases in postoperative complications, including respiratory failure, pulmonary embolism, deep vein thrombosis, sepsis and abdominal wound separation/splitting.

The survey found that safety problems cost Medicare nearly $9 billion. Health Grades also said that if all U.S. hospitals reached the same level as the top performing facilities, Medicare would save about $2 billion.

The growing toll of C. difficile

THE NUMBER OF HOSPITALIZED PATIENTS who developed C. difficile or a C. difficile related disease increased by 200% between 2000 and 2005. That spike follows a 74% increase in the incidence of the infection between 1993 and 2000.

Here are more details from the report, which was released by the Agency for Healthcare Research and Quality.

  • There were more than 2 million cases of C. difficile between 1993 and 2005.
  • In 2005, two out of three infected inpatients were elderly.
  • Patients with C. difficile were in the hospital almost three times longer than uninfected patients.
  • The in-hospital mortality rate for these patients was 9.5%, compared to 2.1% for all patients.
  • The highest rate of C. difficile inpatient infection was in the Northeast, with 144 cases per 100,000 population.
  • The lowest rate of C. difficile infection in hospitals was in the West, with 67 cases per 100,000 population.

Source: Agency for Healthcare Research and Quality