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News of the Day ... In Perspective


Medicare to stop paying hospitals to treat "preventable" complications

A new CMS rule to take effect in October 2008 will deny payment to hospitals for complications that it thinks could have been prevented using “evidence-based” guidelines. The conditions include urinary infections in patients with catheters; surgical site infections, such as mediastinitis after coronary artery bypass graft; vascular catheter-associated infection; hospital-acquired injuries, such as fractures; and hospital-acquired pressure ulcers. Reporting is to begin October 2007.

Conditions under consideration for adding to the list in 2009 include ventilator-associated pneumonia, Staphylococcus aureus septicemia, and deep-vein thrombosis. Conditions to be analyzed for possible future inclusion are methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile-associated disease.

“We think this is groundbreaking that Medicare now says, ‘We’re not going to pay you extra when you’ve done something to harm a patient,’” said Lisa McGiffert, who runs a Consumers Union campaign to stop hospital infections. She says the change will force hospitals to use established prevention guidelines.

CMS administrator Tom Valuck predicts a cascade of savings, from less home health care and less ambulatory care, if hospitals reduce costly complications.

The CDC estimates that there are 500,000 catheter-associated urinary infections each year, costing $451 million to treat. If Medicare refuses to pay, hospitals won’t be allowed to charge patients either, Valuck says.

“We are transforming Medicare from a passive player simply processing claims to an active purchaser with a stake in quality and efficiency,” he states.

Private insurers are looking carefully at these Medicare changes (Newark Star Ledger 8/13/07).

The 2,140-page rule is not entirely clear on how CMS will determine whether an infection was preventable. The rule states: “[W]e are only selecting those conditions where, if hospital personnel are engaging in good medical practice, the additional costs of the hospital-acquired condition will, in most cases, be avoided, and the risk of selectively avoiding patients at high risk of complications will be minimized.”

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