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Medicare Says 'No' to Bed Sores and Other Hospital Complications

By Cindy Skrzycki
Tuesday, October 21, 2008

Hospitals will no longer get paid for some specific treatment errors, including infections, bed sores and objects left inside patients after surgery, under a new Medicare policy.

Regulators at the Centers for Medicare and Medicaid Services told about 3,500 U.S. hospitals that as of Oct. 1, they won't be reimbursed for such so-called "never events" that patients should never acquire during a hospital stay. The dozen treatment areas on the list are considered "reasonably preventable" and aren't present when a patient checks in.

In an Aug. 19 final rule, the government estimated that some $21 million would be saved annually by not paying for 500,000 follow-up procedures to correct complications from the hospital hall of horrors. That's a drop in the catheter compared with the $110 billion in payments Medicare makes to hospitals each year.

Still, officials say the payoff will be in improving the standard of care, focusing hospitals on prevention and saving patients the pain of unnecessary treatment.

"It's a sea change, and we hope this is just the beginning," said Herb Kuhn, deputy administrator of the Centers for Medicare and Medicaid Services. "When you enter a hospital, you don't want to leave with something else. Let's get it right the first time."

Overall, medical errors, including those just targeted, cost as much as $29 billion annually and result in 98,000 deaths, according to a landmark 1999 study.

Hospital professionals say the government is setting an impossible standard.

"It's frustrating to be held accountable for things you can't prevent," said Nancy Foster, vice president of quality and patient-safety policy at the American Hospital Association. She said there are items on the list that "we don't know how to make never happen."

She suggested that bed sores and falls are tough to prevent when a frail patient might already have skin problems, or a patient doesn't call a nurse for help moving and then falls.

J. James Rohack, president-elect of the American Medical Association and a cardiologist in Texas, said Medicare should be investing in research to eliminate these kinds of problems. Instead, he said, regulators are implementing a "pay for perfection" system that isn't supported by science and ultimately may result in certain procedures not being done on high-risk patients.

Tests at hospitals in Michigan have shown that following strict procedures for inserting central blood lines in patients in intensive care units reduced the number of infections to almost zero. Within three months, the program eliminated infections in more than half of the participating hospitals, according to government officials.

The Agency for Healthcare Research and Quality, a federal agency that supports such initiatives, announced Oct. 1 that it awarded a $3 million grant to spread the program to other hospitals.

States and private insurers also have begun to ask for more reporting of errors.

About 20 states already require reporting of medical errors such as those on the Forum's list of 28 preventable medical "events," said Janet Corrigan, president and chief executive of the National Quality Forum, a nonprofit group that sets standards for measuring and reporting health care.

"We know we can get very close to eliminating them," Corrigan said, if there is no reprisal against hospital workers who report mistakes, and if procedures are standardized so there is less reliance on memory and more on checklists and reminders.

Some patient advocates say that denying payments could hurt patients and lead to billing disputes among patients, hospitals and Medicare.

"Beneficiaries who fit certain illness profiles will not get services," said Alfred Chiplin, senior policy attorney for the Center for Medicare Advocacy. "Say someone comes in from a nursing home with pneumonia. Do they bring them in or pump them with an antibiotic and send them home?"

Paul H. O'Neill, a former Treasury secretary who has been involved in several health-care initiatives in Pennsylvania, says Medicare's emphasis is wrong.

"There are still an enormous number of errors, and at the crux of the problem is how do we eliminate this stuff? If we eliminate it, we don't have to pay for it at all," he said.

O'Neill suggested that Medicare fund several demonstration programs with hospitals that agree to work on eliminating errors. He is concerned the new rule could lead to less reporting of errors, since an analysis in Pennsylvania shows hospitals underreport mistakes.

Medicare's Kuhn said he expects reporting will be accurate. Regulators will watch claims closely, especially for how patients are screened and classified when being admitted to the hospital, he said.

The government may add more "never events" to the list, refusing payment for certain egregious surgical mistakes and extending the policy to outpatient settings.

"We have definitely gotten their attention," Kuhn said.

Cindy Skrzycki is a regulatory columnist with Bloomberg News. She can be reached at skrzycki@bloomberg.net.

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