Thursday, October 2, 2008
The New York Times reports that Medicare has compiled a list of ten "reasonably preventable" conditions and will not reimburse hospitals if a patient develops one of those conditions while in the care of the hospital. Kevin Sack writes,
If an auto mechanic accidentally breaks your windshield while trying to repair the engine, he would never get away with billing you for fixing his mistake. On Wednesday, Medicare will start applying that logic to American medicine on a broad scale when it stops paying hospitals for the added cost of treating patients who are injured in their care.
Medicare, which provides coverage for the elderly and disabled, has put 10 “reasonably preventable” conditions on its initial list, saying it will not pay when patients receive incompatible blood transfusions, develop infections after certain surgeries or must undergo a second operation to retrieve a sponge left behind from the first. Serious bed sores, injuries from falls and urinary tract infections caused by catheters are also on the list.
Officials believe that the regulations could apply to several hundred thousand hospital stays of the 12.5 million covered annually by Medicare. The policy will also prevent hospitals from billing patients directly for costs generated by medical errors.
Because Medicare is the largest insurer in the country, its decision to refuse payment for preventable conditions has already influenced others — public and private — to set similar criteria.
Over the last year, four state Medicaid programs, including New York’s, have announced that they will not pay for as many as 28 “never events” (so called because they are never supposed to happen). So have some of the country’s largest commercial insurers, including WellPoint, Aetna, Cigna and Blue Cross Blue Shield plans in seven states.
A number of state hospital associations, including here in Minnesota, have brokered voluntary agreements that members will not bill for medical errors. In April, Maine became the first state to ban the practice statutorily.
The Congressionally mandated Medicare measure is not projected to yield large savings — $21 million a year, compared with $110 billion spent on inpatient care in 2007. But it carries great symbolism in the Bush administration’s efforts to revamp the country’s medical payment system, which has long been criticized as driving up costs through perverse incentives that reward the quantity of care more than the promotion of health.
The real money, many health economists believe, may come from reorienting the payment system to encourage prevention and chronic disease management and to discourage unnecessary procedures. The two major-party presidential candidates support such a realignment, a rare point of consensus in a polarized health care debate.
“This is a specific case of the larger pay-for-performance trend, the idea that you should pay more for quality than lack of quality, or in this case pay less for defects,” said Dr. Donald M. Berwick, president of the Institute for Healthcare Improvement. “This whole trend is like a juggernaut, and it is not going to stop.”
Pay-for-performance makes use of both the carrot and the stick. Medicare now grants bonuses to doctors and hospitals that report quality measures. It is experimenting with rewarding physicians who follow protocols for treating diabetes, coronary artery disease and congestive heart failure. The Medicare Payment Advisory Commission, an arm of Congress, recently recommended reducing payments to hospitals with high readmission rates.
Three years ago, HealthPartners, a Minnesota-based health maintenance organization, was first in the country to refuse payment to hospitals for never events. Company officials said the policy has yet to save much money. But at Regions Hospital in St. Paul, which is owned by HealthPartners, the change has reinforced a new focus on reducing medical errors.
“Historically, there’s been some acceptance that these things happen,” said Brock D. Nelson, the hospital’s president. “We’ve come to now accept that they’re avoidable. And that’s a sea change.”
Some improvements have been technological, like an electronic prescribing system that has helped cut medication errors in half. Others are breathtaking in their obviousness, like diligent hand-washing.
Nurses have been trained to provide more information during shift changes about whether patients are prone to falls. High-risk medications like heparin are now marked with pink labels to ward against mix-ups.
Shortly before Cynthia A. Kehborn’s recent ankle fusion surgery, her orthopedic surgeon, Dr. Peter A. Cole, checked records and asked her repeatedly whether he would be operating on her left leg. He then took a sterile marker and signed his initials on her left ankle.