Commentary by Zackary Berger MD PhD, PGY-2
A recent article in the New York Times publicized changes in Medicare subsidies. In the article’s own words, “Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move [that] could save lives and millions of dollars.” This change was widely discussed, no less so in our hospitals.
But the devil is in the details. What is a preventable error? How was the list modified, and whose idea was this in the first place? What are the implications for our daily practice?
To understand, return for a moment to 2006. Among the notable events of last year was the passage of Public Law 109-171, a huge budget bill. Section 5001 (Hospital Quality Improvement) mandated that Medicare modify its payment system to take into account conditions that “could reasonably have been prevented under evidence-based guidelines.” More particularly, Medicare was ordered to identify ICD-9 codes for conditions that are (a) common or expensive; (b) associated with cost increases in a given case; and (c) reasonably preventable.
Through 2006 and 2007, Medicare solicited public comments about which conditions to include. No explicit definitions of prevalence, cost, “evidence-based,” or “reasonable” were specified in the law. Evidence-based medicine, in this case as well as in general, meant whatever expert opinion says it does.
After all was said and done, many conditions were included in the final list: infections from urinary catheters, infections from central venous catheters, pressure ulcers, objects left in the body after surgery, air embolism, injuries from blood incompatibilities, mediastinitis as a complication of heart surgery, and falls.
Even more interesting, perhaps, are the conditions which did not meet the specified criteria: surgical site infections, ventilator-associated pneumonia, Staph aureus bacteremia, methicillin resistant Staph aureus infection, deep venous thrombosis, and Clostridium difficile colitis. While several of these will be considered in future years for inclusion on the “do-not-reimburse” list, they weren’t listed this year for a variety of reasons. In the case of ventilator associated pneumonia, a consensus definition of the condition itself is lacking. While Staph aureus infection and MRSA are certainly prevalent, without widespread screening (a strategy that some advocate) before admission, it is difficult to know whether the bacteremia was present before the patient came to the hospital. Similarly, only routine admission screening would establish whether DVTs found in the hospital are new or old. C. difficile colitis is a difficult case both because C. difficile is a prevalent organism in the healthy population, and because the colitis is often not preventable – just the opposite, because the antibiotics which place the patient at a greater risk are necessary for treatment.
How will this list of non-reimbursable conditions (and those which might be included in the list in the future) affect our current care? Unsurprisingly, institutions like our own will try and incorporate professional guidelines for the prevention of these conditions into their day-to-day practice. Which hospitals will try to get ahead of the game, and which of the conditions that are not yet non-reimbursable will they try to limit through systems-based initiatives? Stay tuned for new regulations in your mailbox.
Image courtesy of Wikimedia Commons