MASSACHUSETTS NURSE NEWSLETTER :: January 2008

National reimbursement news which impacts Massachusetts:
Medicare to stop paying for ‘medical errors’
By Mary Crotty

Huge changes have been announced by Medicare in recent months which will impact the delivery of health care today. And already nurses are seeing new pressures as a result.

This summer the Bush Administration announced that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars. The Centers for Disease Control and Prevention (CDC) estimates that patients develop 1.7 million infections in hospitals each year, and it says those infections cause or contribute to the death of 99,000 people a year—about 270 a day. Private insurers, such as Blue Cross, have already announced they are considering similar changes.

Under the new rules, as of Oct. 1 2008, Medicare will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.”

The conditions for which Medicare no longer will reimburse hospitals for treatment include:

• Falls
• Mediastinitis, an infection that can develop after heart surgery
• Urinary tract infections that result from improper use of catheters
• Pressure ulcers
• Vascular infections that result from improper use of catheters

• Objects left in the body during surgery
• Air emboli
• Blood incompatibility

Three additional conditions will be included a year from now (MRSA, clostridium difficileassociated disease and wrong-site surgery).

Following the money trail
These changes represent the start of the dismantling of Medicare. Debates have already begun about what is (or isn’t) an error, let alone a preventable error, and about patients who come into the hospital with a condition vs. acquiring it in the hospital. Commenting on the proposed rules in June, the American Hospital Association said, “Certain patients, including those at the end of life, may be exceptionally prone to developing pressure ulcers, despite receiving appropriate care.” As a consequence, legions of financial analysts and attorneys are going to be required to sort this out, which ought to drive up even higher the current 31 percent of the healthcare dollar that Americans spend on unnecessary administrative costs rather than on actual care. Finally, if insurance companies won’t be paying for these medical bill, who will? The final rules from the Centers for Medicare & Medicaid Services (CMS) say, “The hospital cannot bill the beneficiary for any charges associated with the hospital-acquired complication.” However, the indirect costs are inevitably going to be passed along to patients. Another theory is that insurance companies will seize the opportunity to start writing coverage for medical errors—another potential bonanza for the insurance industry.

New burdens on nurses and clinicians
Clinically, the reimbursement changes are already impacting—negatively—the way care is delivered. The potential for unforeseen outcomes is rearing its ugly head before the final changes even roll out. Experts predict changes in medical practice as doctors hew more closely to clinical guidelines and hospitals perform more tests to assess the condition of patients at the time of admission. MNA has already heard nurses voice concern over pressure to do complete skin assessments upon admission, in ER settings, etc.—and to extensively chart these (to demonstrate pre-existing conditions for reimbursement reasons). The danger is for skin assessment to take priority over what could be more urgent assessment or clinical needs.

Obviously complete assessments, including assessments of skin integrity are important. The worry is that drivers of payment/reimbursement end up unduly inf luencing clinical practice and causing greater harm. Hospital executives have voiced concern that finances will be impacted by the need to absorb the costs of extra tests to prove patients came into the hospital with MRSA (or whatever) to avoid the new financial penalties.

Reducing errors and infections
A number of demonstration projects across the country have shown that it is possible to reduce, for example, ventilator-associated infections to zero, leading officials to believe that if it can be done in one institution, it can be done everywhere. Theoretically this may be true, but the institutions that have had isolated successes have generally been working diligently for several years on tackling a single issue. The reimbursement changes requires a massive acceleration of this process nationwide practically overnight. Even though the final penalties do not start until Oct. 1, 2008, there is a sequence of events related to policy and procedure and coding changes already underway. Just how many task forces are being pulled together to work on the multiple issues at any one institution is anyone’s guess.

As an example, Michigan hospitals have been extremely successful in reducing bloodstream infections related to catheters, researchers reported recently in The New England Journal of Medicine. The hospitals did not use expensive new technology, but systematically followed well-established infection-control practices, like covering doctors and patients from head to toe with sterile gowns and sheets while the catheters were inserted. Hospital executives said these techniques had saved 1,700 lives and $246 million by reducing infection rates in intensive care units since 2004, when the project began. Unfortunately, other institutions are now expected to replicate the Michigan success, but without time to ramp up.

Safe staffing is the key
In the opinion of the MNA, the prevention of medical errors and hospital acquired infections lies not in mandating penalties for poor care, but in providing nurse staffing levels in hospitals that are scientifically proven to prevent them from happening in the first place. One recent study by Patricia Stone in the journal Medical Care found that improving RN to patient ratios in ICUs could reduce hospital acquired infections by 65 percent. Safe staffing legislation must be part of the approach to this crisis, and the evidence shows it is the most cost-effective approach.

A word of caution
Dr. Kenneth W. Kizer, an expert on patient safety who was the top health official at the Department of Veterans Affairs from 1994 to 1999, has said: “I applaud the intent of the new Medicare rules, but I worry that hospitals will figure out ways to get around them. The new policy should be part of a larger initiative to require the reporting of health care events that everyone agrees should never happen. Any such effort must include a mechanism to make sure hospitals comply.” Words to remember— Dr Kizer has been credited with a massive turnaround of the VA healthcare system to the extent it could be a national model for healthcare reform.

For more information contact Mary Crotty at 781.860.5743 or via e-mail at mcrotty@mnarn.org.