CMS wants to double list of conditions for which it will not pay a higher rate
CMS wants to double list of conditions for which it will not pay a higher rate
Focus is on hospital-acquired conditions not present on admission
In a move that has generated great concern in the ED community, the Centers for Medicare & Medicaid Services (CMS) is proposing to more than double the list of hospital-acquired conditions (HACs) for which it will no longer pay hospitals at a higher rate for the resulting increased costs of care. Those conditions are:
- surgical-site infections after total knee replacement, laparoscopic gastric bypass and gastroenterostomy, or ligation and stripping of varicose veins;
- Legionnaires' disease;
- diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma, or hypoglycemic coma;
- iatrogenic pneumothorax;
- delirium;
- ventilator-associated pneumonia;
- deep-vein thrombosis or pulmonary embolism;
- Staphylococcus aureus septicemia;
- disease associated with Clostridium difficile (C-difficile).
These would be added to the eight HACs currently in force:
- object left in the patient following surgery;
- air embolism;
- blood incompatibility;
- catheter-associated urinary tract infections (UTI);
- pressure ulcers;
- vascular catheter-associated infections;
- surgica- site infections;
- falls in trauma.
The new rule would become effective Oct. 1, 2008. The final rule will be issued at the beginning of August.
Emergency medicine experts argue that many of these conditions are not totally preventable (i.e., UTIs) and therefore would unfairly penalize the hospital for what might credibly be called appropriate care. They also foresee an onerous documentation burden and fear that some hospitals might pressure EDs to not admit older patients with multiple comorbidities, lest one or more of those conditions might develop further after admission.
What's more, the proposed rule is part of a bigger picture that surrounds a move toward "nonpay for nonperformance." In addition to CMS, the National Quality Forum has compiled its own list of what it calls "never events," or events that should be preventable. Several hospitals have indicated that they will no longer charge patients when some or all of these events occur, and leading insurance companies are following suit. Some states, such as Massachusetts, are even proposing to link accreditation to how well hospitals avoid these events.
"Right now, CMS is purporting to be more of a value-based purchaser, so instead of paying based on volume they say they will pay for quality," says Dennis Beck, MD, FACEP, president and CEO, Beacon Medical Services, an Aurora, CO-based practice management firm that provides coding and billing services for emergency physician groups. "My question is, are we really rewarding quality, or figuring out ways to reduce payment?"
The momentum, however, may be irreversible. "WellPoint, Anthem [Health], they're all jumping into this, and hospitals are saying there are certain never events they ought not to charge for," says Beck, who also chairs the quality and performance committee of the American College of Emergency Physicians.
However, it's important to keep things in perspective, says Charlotte S. Yeh, MD, FACEP, CMS regional administrator in Boston. "Remember the big picture: If you look at Medicare, we spend over $1 billion a day on health care; and in 10 years, one out of every five dollars [in the budget] will be spent on health care. With that, people are asking that we get what we pay for."
Yeh cites studies indicating that Medicare patients only get 65% of the recommended care. CMS is part of a much larger national movement to spend health care dollars wisely and get good quality of care, she says. "Every ED manager and doctor I know deeply care about providing quality care," Yeh says.
What's missing, she contends, are incentives to have systems in place to really facilitate that type of care. "This is a pretty major step Medicare has taken, but we know through research that some of these complications are preventable," says Yeh.
She emphasizes that CMS is only talking about not paying for these complications; the basic care still will be reimbursed. As for preventing these "preventable" events, Yeh says, "I don't think any one of us would say that is not our goal."
Is CMS reasonable?
For Beck, the issue is not whether quality is important, but whether what CMS is requiring makes medical sense.
"My question is: Is this something that is reasonably preventable?" he asks. "Take pulmonary embolism, for example. What actions by a doctor would be likely to prevent this?"
Jedd Roe, MD, MBA, FACEP, chairman of emergency medicine at William Beaumont Hospital in Royal Oak, MI, says, "UTIs and Foley catheters concern me a lot. We will probably be scrutinized more than we have in the past for when we place the catheter, and a lot of times we can't do it right away." One of the key considerations, he points out, is whether the purpose of the catheter is therapeutic or diagnostic.
There are going to be challenges that occur at the direct care level in the ED, Yeh concedes, "but the challenge to the ED is to do what it can to mitigate those challenges." All providers need to be working toward the goal that no patient has UTIs or pressure sores, which is a real challenge with patients transferred from nursing homes, "because nobody wants these complications," she says.
In many of these situations, Yeh says, preventing complications is "difficult but not impossible." For example, she notes, many say that ventilator-associated pneumonia is unavoidable in some cases, "but there are some hospitals that have gotten them down to zero."
Unintended consequences
Roe is concerned that by seeking to avoid this lost revenue, some EDs may fall victim to unintended consequences.
"If you place a Foley catheter in your ED, you may feel obligated to give a dose of ciproflaxin at the same time to reduce the likelihood of infection, but you then risk an antimicrobial situation where you would have more C-difficile [which also carries a financial penalty], prolonged lengths of stay, and so forth," he says. "The ED is left to try and come up with systems and plans to address these unintended consequences, so the impact is not just from an operational standpoint but from the aspect of clinical care as well."
Such options also may force hospitals to conduct financial analyses to see what treatment regimen is "best for the money," Roe says.
Beck agrees. "These measures will require EDs to change how they practice medicine," he says. For example, he asks, would the fear of financial penalty due to vascular catheter associated infections "dissuade someone from putting in a central line or putting it in under emergent conditions but not having the time to put in full barrier protection?"
Roe also is concerned the new measures will require more documentation. "With decubitis ulcers and UTIs, we will have to document the existing conditions well, and that will put a lot more pressure on docs and nurses," he says.
Beck says, "These measures do create an onus or burden to document what's present on admission, but it's not clear from the regulation that it is the ED's responsibility. It could be done by the admitting physician or hospitalist."
And what about the fear that EDs will be pressured to not admit certain patients? Pressure not to admit is a legitimate concern, says Beck. On the other hand, Roe says, "I'm not so sure, though it may be there to a small degree. Many of these people are nursing home patients, and they often have a bunch of other things they need to be admitted for."
Sources
For more information on the regulations concerning hospital-acquired conditions, contact:
- Dennis Beck, MD, FACEP, President and CEO, Beacon Medical Services, Aurora, CO. Phone: (303) 306-4560. E-mail: [email protected].
- Jedd Roe, MD, MBA, FACEP, Chairman of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI. Phone: (248) 898-1969.
- Charlotte S. Yeh, MD, FACEP, Regional Administrator, Centers for Medicare & Medicaid Services, Boston. Phone: (617) 565-1188.
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