Medicare nixes payment for more 'never' events: 'this is about changing hospitals and making them safer places.'

Skin & Allergy News,  Sept, 2008  by Mary Ellen Schneider

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Starting Oct. 1, Medicare won't pay for a total of 11 preventable conditions acquired during a hospital stay, up from the current 8 such conditions. Added to the list of noncovered preventable conditions are surgical site infections following certain elective procedures, such as orthopedic surgeries and bariatric surgery for obesity; manifestations of poor glycemic control; and deep vein thrombosis or pulmonary embolism following certain orthopedic surgeries, such as total knee replacement and hip replacement. (See box for current list of preventable conditions.)

The new conditions were included in the Acute Care Hospital Inpatient Prospective Payment final rule, which was slated to be published in the Federal Register and released on the Centers for Medicare and Medicaid Services' Web site.

The expansion of the preventable conditions list was criticized by the American Medical Association for putting patient care at risk. The AMA said that Medicare officials are lumping together true "never" events such as wrong-site surgery with "often unavoidable" conditions such as surgical site infections.

"Focusing on determining whether or not medical conditions exist when the patient enters the hospital will increase Medicare spending on tests and screenings with questionable benefit to patients," Dr. J. James Rohack, AMA president-elect, said in a statement. "A more effective patient safety approach would be to encourage compliance with evidence-based guidelines by health care professionals.'"

Officials at CMS estimate that the nonpayment for preventable errors policy will save Medicare about $20 million a year. However, the policy is not about saving money, Kerry Weems, CMS acting administrator, said during a press conference.

"I would be perfectly happy if we never came to a point where we didn't have to pay because somebody got a hospital-acquired condition," Mr. Weems said. "This is about changing hospitals and making them safer places."

The CMS originally had proposed adding nine new conditions to the preventable conditions nonpayment list. Agency officials pared down the list after public comments raised questioned about including the other conditions. Some conditions that were not included in the final rule are delirium, ventilator-associated pneumonia, Staphylococcus aureus septicemia, Clostridium difficile-associated disease, legionnaires' disease, and iatrogenic pneumothorax.

However, those conditions may appear in future proposals once the agency has refined them, according to Mr. Weems.

The CMS also is in talks with the National Quality Forum, the Agency for Healthcare Research and Quality, the Leapfrog Group for Patient Safety, and others about expanding the list of never events and considering how to expand the nonpayment policy to non-hospital settings such as nursing homes and home health agencies.

In addition to the expansion of the conditions on the preventable hospital-acquired conditions list, CMS is also beginning to develop three National Coverage Determinations to deny Medicare coverage for three never events--surgery on the wrong body part, surgery on the wrong patient, and wrong surgery performed on a patient.

"These national coverage decisions will mandate what seems obvious--never events should never occur," Mr. Weems said. "They should not be reimbursed by the Medicare trust fund."

A proposed decision memorandum on these surgical errors is scheduled to be issued by next February and is expected to be made final by the end of next April.

Including these events in Medicare's coverage policy also would apply to Medicare Advantage plans. Medicare Advantage plans are required to follow all Medicare fee-for-service coverage policies, even when those policies differ from their commercial practices, according to the CMS.

The CMS also sent a letter to state Medicaid directors to encourage states to adopt similar policies on payment for preventable hospital-acquired conditions. The letter also provides information on how states can adopt the policies outlined in the final Medicare inpatient prospective payment system regulation.

Nearly 20 states are considering methods to eliminate payment for certain never events, or already have them in place, according to the CMS.

Finally, as part of the Acute Care Inpatient Prospective Payment System final rule, the CMS is adding 13 new measures to the Reporting Hospital Quality Data for Annual Payment Update program. Under the program, hospitals are required to report quality data publicly on the Medicare Hospital Compare Web site in order to receive their full payment update. The payment implications for the new quality measures will take effect in fiscal year 2010.

"Not only will the measures promote quality improvements by hospitals and their staff, they will also allow patients to compare different hospitals, to [help them] decide where they will receive the best care," Mr. Weems said.