New CMS rules concerning hospital reimbursement and adverse events

Recently JAMA published a commentary on this issue with a focus on urinary tract infections (UTIs). The new policy has sparked controversy and was number 6 in my top ten list of issues in hospital medicine for 2007.

Urinary tract infection is not a particularly good example for examination of the controversy. The rule concerning UTI is among the least controversial and is not as manifestly unfair as those concerning patient falls and decubitus ulcers. Although there will be unintended consequences (expect a sharp rise in urine cultures on admission whether clinically indicated or not, especially in nursing home patients) hospitals may find constructive ways to respond to the rule, such as designating urinary catheter cops to do daily chart reviews and coax doctors to remove catheters after 48 hours unless there’s a darn good reason to leave them in. Some patients will still acquire UTIs in the hospital in spite of this and other best practices. Unfortunately, these infections will nevertheless be considered “mistakes.”

I was particularly interested in the authors’ analysis of the financial incentives involved. Although I don’t have data to refute it, it seems flawed to me:

Simply stated, the IPPS tolerates and even financially rewards poor performance by hospitals that fail to prevent hospital-acquired complications such as catheter-associated UTIs. For example, at the University of Colorado Hospital, the care of a patient with acute myocardial infarction discharged alive without a complication or comorbidity or a major complication or comorbidity would result in a Medicare reimbursement of $5436.66. The care of an identical patient with the complication or comorbidity of UTI would result in a reimbursement of $6721.44 and that of an identical patient with the major complication or comorbidity of Escherichia coli sepsis and infection due to indwelling catheter would result in a reimbursement of $8905.43.

The rule change is designed to eliminate these perverse financial incentives.

So they’re saying, in effect, that hospitals have been incentivized to allow patients to experience complications! But that’s based on the dubious assumption that the increase in DRG reimbursement exceeds the added cost of caring for patients who have experienced complications in the hospital. The example given assumes that an extra $3468.77 would more than pay for an episode of sepsis. But what if the patient’s sepsis requires 10 days of big gun antibiotics, the use of activated protein C, consumes the resources of an early goal directed therapy team and requires 5 days in the ICU? Hospital resource managers know better and, ever since the advent of DRGs in 1984, have considered such events to be costly.