What's been the impact of the 2008 law that empowered Medicare to refuse payment for additional care necessitated by so-called "never events" such as wrong-site surgeries and healthcare-associated infections that should never be allowed to happen?
The Centers for Medicare & Medicaid Services initially estimated it would avoid spending $20 million the first year the policy was in place and $50 million in subsequent years.
As it turns out, Medicare hasn't avoided much spending, because most patients who incurred harm were already so sick, their disease co-morbidities resulted in diagnostic codes that paid higher payments for their care anyway. One 2010 report pegged the non-payments to hospitals as low as $2.4 million nationally.
But even if the "no-pay-for-harm" law hasn't dented hospital revenue, it has prompted hospitals to increase attention at the front lines to avoid healthcare associated infections. These efforts, however, come at the expense of other quality endeavors, according to a report from Harvard Medical School researchers.
"With the advent of the CMS HAC policy, the vast majority, three-quarters of hospitals, didn't get additional funding in order to be able to respond to the policy," says Grace Lee, MD, of Harvard Pilgrim Health Care Institute and lead author of a report in the American Journal of Infection Control which surveyed infection preventionists at 317 hospitals in the country.
"As a consequence, some hospitals reported they needed to shift their resources and their efforts to be able to respond," specifically to efforts that prevent central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI).
The fact that the Affordable Care Act calls for public reporting of each hospital's HACs, and a separate penalty, has played a role as well, Lee says. "Notoriety from public reporting is important. It's a strong incentive," that has hospital leadership to give a stronger response to these efforts.
The infection preventionists told the Harvard researchers that it was their perception that they didn't have enough resources to focus on things that were more important, Lee adds. "For example, some hospitals felt that catheter-associated urinary tract infections, a CMS reduction target, resulted in lower morbidity and mortality and lower cost, and less of an impact on the patient."
Improving physician documentation and surveillance to capture those times when patients were already infected when they came to the hospital, with "present on admission" coding, is being emphasized far more. And less time is spent educating clinicians on handwashing, and in preventing infections in other ways, she says.
Among some of the researchers findings:
- 81% of the infection preventionists who responded report that their hospitals now put greater focus on those healthcare-associated infections that CMS targets for non-payment. However, in one-third of the hospitals, the policy has resulted in less time spent on preventing non-targeted healthcare-associated infections.
- A majority of respondents said they spend more time on surveillance of patients for CAUTIs because of the new law. For example, front line staff are quicker to remove urinary catheters and central venous catheters when they're not needed.
- More than one-third of hospitals' preventionists said they more frequently use antimicrobial-coated or impregnated urinary catheters.
- One-third of hospitals said they use diagnostic tests without clinical indication, for example, routinely obtaining urine and blood cultures on admission to document presence of infections to avoid getting blamed later for causing them, and having to absorb a Medicare financial penalty.
The law that took effect in 2008 was part of the Deficit Reduction Act of 2006. And according to an Office of Inspector General's report from November, 2010, the codes for hospital-acquired conditions "often had no effect on costs because the claims included other costly diagnoses or procedure codes that elevated the reimbursement to equivalent or higher amounts."
The OIG report estimated that hospital care associated with events resulting in adverse and temporary harm cost Medicare an estimated $324 million in one month, October of 2008. Of those events, the OIG estimates, 44% are preventable.
"Costs associated with preventable events accounted for an estimated $119 million of the $324 million additional cost, equating to 1.3 percent of the $9.2 billion Medicare inpatient expenditures for the month or about $1.8 billion annually," the OIG report said.
Of all such never events, those related to medication accounted for 31%; those related to ongoing patient care, 28%; events related to surgery or other procedures, 26%, and events related to infections 15%.