Published in the October 2007 issue of Today’s Hospitalist
This summer, the Centers for Medicare and Medicaid Services (CMS) finally announced plans to make good on a threat it has bandied about for some time. As of Oct. 1, 2008, Medicare will no longer reimburse hospitals for the costs of treating what the agency considers to be preventable inpatient complications, unless those conditions are also secondary diagnoses on admission.
While the list of conditions includes some slam-dunk errors like leaving a sponge or object in a patient during surgery, several conditions are complications that hospitalists may see every day, such as decubitus ulcers and catheter-related infections. (For a full list of the conditions, see “The CMS’ list of preventable complications.”) As a way to phase in the new non-payment policy, the CMS is asking hospitals this month to begin reporting when those conditions are secondary diagnoses on admission.
To get an idea of how the new rule will affect hospitalists, we talked to an expert in health policy and a veteran hospitalist. Here’s what they had to say.
The use of financial incentives
According to Robert Berenson, MD, an internist and senior fellow specializing in health care policy at the Washington-based Urban Institute, Medicare’s new no-pay plan for preventable complications is an improvement over CMS’ pay-for-performance and pay-for-reporting initiatives.
“The difference is that this is integrated into basic payment policy and doesn’t require new measurement tools, whereas pay for performance does,” he points out.
Another big plus: Many conditions that the CMS has flagged as preventable actually have some evidence behind them, unlike some pay-for-performance or for-reporting measures. (Dr. Berenson singles out some measures that are part of the physician quality reporting initiative that he claims are “not evidence-based, but politically-based.”)
And while estimates differ on how much not paying to treat preventable complications will save Medicare, Dr. Berenson says that cost savings aren’t the point. “The issue is: Let’s get our feet wet in how hospitals respond to financial incentives,” he says. “The issue is finding a strategy that can be expanded for lots more savings down the road.”
Dr. Berenson takes on some objections that have been made about the new policy. Take, for instance, the charge that it will lead to unnecessary tests on admission to prove that what may be deemed a preventable complication, such as a catheter- related urinary tract infection, was already present.
“I think that argument is sort of silly,” says Dr. Berenson. Because hospitals will be at risk for basic payments, he reasons, they’re not going to start ordering tests for patients in whom they suspect no underlying infection.
Chief medical officers should, on the other hand, begin convening meetings to discuss the issue of tests for patients who may indeed have secondary diagnoses on admission. “If some testing makes sense clinically and from a cost-effectiveness point of view,” he notes, “that might actually improve patient care.”
Hospitalist and patient safety expert Sanjay Saint, MD, has likewise heard those concerns and predicts that some testing may bump up at first. But he agrees with Dr. Berenson that inappropriate testing probably won’t be dramatic.
Instead, he thinks that hospitals will move to make systems changes to help prevent hospital-acquired complications. One such change that hospitals should consider, says Dr. Saint, is hiring patient safety professionals, many of whom come from a nursing background.
Such professionals would act as another “set of eyes,” in addition to physicians and nurses, to monitor just these types of complications.
“They would make sure that patients with urinary catheters have them removed in a timely manner or see that patients get prophylaxis for VTE,” he says. “They’d see if patients have the right type of mattress or deal with a medication regimen that could lead to falls.”
While that type of redundancy is expensive, he notes, “it’s probably worth it.”
Dr. Saint also says that he expects some pushback to the new no-pay policy. “Some of these complications just aren’t preventable because some patients will develop a decubitus or a UTI despite every effort,” he points out. Hospitals that systematically take sicker or more complicated patients, he adds, are the ones “you’re going to hear from after these rules take effect.”
Dr. Berenson agrees that some of CMS’ “preventable” complications are not always avoidable. But he doesn’t think the new policy will lead to hospitals “cherry picking” only healthier patients, a concern that some commentators have voiced.
“The key here is that hospitals are not going to be paid nothing,” says Dr. Berenson. Even when patients develop a flagged complication, hospitals will still get the average DRG payment, he notes, just not the increment for a higher DRG to treat the complication. “I don’t think that most hospitals want to be in the business of saying, ‘We don’t want your patients because they may get decubiti.’ ”
Impact on hospitalists
While the new CMS policy should be a boon for patient safety, Dr. Berenson continues, it’s a huge plus for hospital medicine, a field that he calls a “fascinating innovation that has gotten not nearly enough policy attention.”
The new incentives will accelerate the ongoing collaboration between hospitals and hospitalists, he says. And incentives will further illustrate the fact that physicians who visit the hospital only occasionally cannot take the lead on patient safety initiatives, which now will have financial strings attached.
But what might the new policy mean for individual hospitalists? That depends, says Dr. Saint, who is a researcher at the Ann Arbor VA Medical Center in Ann Arbor, Mich., on how involved hospitalists already are in patient safety efforts.
For hospitalists whose time is totally taken up with clinical care, the incentives may not have much effect, he points out. But for doctors who have taken leadership positions in patient safety and quality improvement, the new incentives present a golden opportunity.
“Hospitalists can step in,” he says, “and solve someone else’s problem.” In leading efforts in response to the new incentives, Dr. Saint advises physicians to find colleagues with whom they can collaborate, such as individual nurses or infection control specialists.
Hospitalists should start by targeting the preventable condition for which the hospital is most vulnerable “and not promise more than they can deliver.
“Start small,” says Dr. Saint, “and then build from success.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
The CMS’ list of preventable complications
This summer, the Centers for Medicare and Medicaid Services (CMS) announced that as of Oct. 1, 2008, it would no longer pay for a higher DRG that includes what the CMS considers a hospital-acquired secondary diagnosis. (It will continue to pay the DRG for the primary diagnosis.)
The eight conditions the CMS now considers to be preventable complications are:
- Air embolisms
- Blood incompatibility for transfusions
- Catheter-related urinary tract infections
- Object left in surgery
- Pressure ulcers
- Vascular catheter-associated infections