Friday, February 22, 2008

Medicare payment and hospital “mistakes”

Ever since my initial rant about the new Medicare policy I’ve waited for Bob Wachter’s take. Wachter is an expert on safety and quality and does his share of preaching about it. Yet, he approaches the subject with a degree of skepticism and humor I find refreshing. You can tell he’s not far from the trenches of day to day patient care.

He finally weighed in with a post on February 11 along with a link to this article he coauthored in The Joint Commission Journal on Quality and Patient Safety. His conclusion was more optimistic than mine despite the fact that he cited virtually all the negatives I did.

Wachter noted four conditions to be met for the policy to be reasonable:

Evidence demonstrates that the adverse events in question can largely be prevented by widespread adoption of achievable practices.

The events can be measured accurately, in a way that is auditable.

The events resulted in clinically significant patient harm.

It is possible, through chart review, to differentiate adverse events that began in the hospital from those that were “present on admission” (POA).

Clearly the policy as written fails to meet condition number one, particularly for decubitus ulcers and patient falls (which Wachter believes should be off the list). Condition number four is problematic. The POA provision will result in system gaming. (Take it for granted that creative hospital charting will rise to a new level).

In his article, Wachter suggests that the policy creates a business case for patient safety. But that implies hospitals didn’t have a business incentive already. A recent paper in JAMA went so far as to say hospitals are currently incentivized to allow adverse events by means of coding modifiers that provide increased DRG payments for complications. I posted a strong disagreement with that thinking and gave the example of hospital acquired sepsis:

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.

And how strong is the business case, really, for prevention efforts? How, for example, and at what expense, can hospitals make patient fall injury a “never event”? Given today’s anti-restraint culture and the recent banning of Vail beds hospitals’ only recourse (unless they want to adopt Happy Hospitalist’s mandatory helmet policy) is to hire a full time sitters for all hospitalized elderly patients. From a purely business point of view (not the point of view I would advocate) hospitals might be better off doing nothing.

Wachter concludes his article with this statement:

In light of all of this uncertainty and risk, “not paying for errors” should be viewed as a bold experiment and its initial implementation a pilot study, whose consequences should be carefully monitored.

That implies that when the unintended consequences surface Medicare will take steps to mitigate them and if the experiment is a failure Medicare will dismantle it. Somehow I’m not comforted. In the 63 year history of this grand experiment’s unintended consequences and abuses, what’s been the track record?

DB weighs in here.

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