What will be the consequences, intended and unintended, of the new Medicare coding rules for adverse events in hospitalized patients?

Recently I objected to the new CMS rules on two principles. First, they are unfair because they operate on a presumption of blame for adverse events, many of which are unavoidable. In addition, as a result of the rules, Medicare Part A, which has under-reimbursed hospitals for a quarter century will now reimburse even less when these events occur. Thus the conflicts of interest created by negative cost incentives built in since 1983 will get even worse in 2008.

But these objections are abstract. What will be the real world impact on patient care? Will mistakes decrease as a result of the new policy? It’s not likely, since the most common events addressed by the new rules are not the result of “mistakes”. As David Catron pointed out in a post entitled Medicare’s Latest Assault on Hospitals:

The new rule is very unlikely to reduce hospital errors. It will, however, reduce the number of hospitals. As I have pointed out here, hospitals cannot operate in the red and survive.

Let’s consider some of the adverse events targeted by the new rules. If there’s one area where patients might benefit it’s the prevention of catheter associated urinary tract infections. Hospitals will have an incentive to implement pathways for limiting the insertion of catheters, and for their early removal.

What about decubitus ulcers? There’s no reason to think the new rules will improve outcomes in this area. Hospitals already have strong medico-legal incentives to avoid decubitus ulcers. (Note that three of the top four Google hits for “decubitus ulcers” are resources for attorneys and legal experts). Hospital nursing staffs are already over taxed, so until researchers at the NCCAM figure out a way to levitate patients the only way to improve prevention efforts will be the more widespread use of expensive high tech specialty beds. Medicare’s negative cost incentives will make this prohibitively expensive, and the most likely way around the problem for many hospitals will be earlier discharge of patients with decubitus ulcers to long term acute care (LTAC) hospitals for “wound care”. That may ease the burden for hospitals but will not benefit patients.

What about fall prevention? Restraints are risky and tend to be restricted by Joint Commission and other agencies. Another proposed solution is the widespread use of Vail beds but these devices are expensive and have been associated with major risks. Ideally, all geriatric patients should be attended by an individual sitter day in and day out. Again, Medicare’s financial incentives will discourage hospitals from doing this. Hospitals, already in a no win situation, will suffer more and patients will not be helped. The unintended adverse consequences will outweigh any benefits.