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How CMS Penalizes Hospitals for Finding Blood Clots

Cheryl Clark, for HealthLeaders Media, October 10, 2013

Starting in less than one year, hospital reimbursement for Medicare patients will be adjusted based on how well they do on PSI-12 in two ways:

  1. Through the value-based purchasing incentive program (it is part of the AHRQ PSI-90 set of eight measures) and
  2. The new hospital-acquired condition penalty, where again it is embedded in PSI-90.

Though PSI-12's weight in each provision is virtually negligible, at most just a few cents for every $100 of Medicare payment, Bilimoria says that's not the point.

"Hospitals have wasted numerous years and millions of dollars trying to chase down their VTE problem and fix things around VTE, when actually they're being presented with flawed data," he says.

Indeed, the data for "serious blood clots after surgery," shows Northwestern Memorial, an academic medical center, with the 23rd highest rate of reportable blood clots among 3,094 hospitals whose VTE rates were reported by CMS. The Chicago facility had 11.85 VTE cases per 1,000 patient discharges.

"That is exactly the point," Bilimoria says. "Of course Northwestern Memorial would have a high VTE rate, because we are very vigilant in looking for VTE. The measure inevitably singles out organizations that are more vigilant in screening their patients for blood clots, but labels them as being worse for it."

Bilimoria says that hospitals should be scored instead on process measures to prevent clots. For example, does the hospital use appropriate screening tools to make sure the right patients get anti-clotting medications or mechanical prophylaxis, such as compression stockings?

This, however, is not yet in hospital pay-for-performance algorithms, and I'm not aware of any plans to put it there.

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