New Medicare rules too harsh, some say

The San Diego Union-Tribune

San Diego-area hospital officials and consumer advocates say they are cautiously welcoming a new federal policy they hope will mean closer scrutiny of patient care — and far fewer mistakes.

Starting Oct. 1, 2008, hospitals will be denied payment for any portion of a Medicare patient’s care required because of a hospital’s mistake. That could include injuries from a patient’s fall or infections from nonsterile procedures.

Previously, hospitals received compensation from Medicare for almost all patient conditions except wrong surgery, regardless of what caused them.

“Hospitals will be much more careful to determine what a patient has, to make sure there’s not a pre-existing condition or some other infection beforehand,” said Steve Escoboza, spokesman for the Hospital Association of San Diego and Imperial Counties. “And frankly, there will be a lot more testing.”

But many health care experts worry that some mishaps are unavoidable, resulting in hospitals being wrongfully penalized. The patients may have pre-existing conditions, though in an early and unrecognizable stage.

“While an object left in during surgery is a clear-cut mistake, some things, such as urinary tract infections and pressure sores, are in a gray area” in terms of their cause, said Debby Rogers of the California Hospital Association in Sacramento.

She said it seems strange that the new federal rules seek to penalize hospitals but not doctors for those mistakes.

Identifying mistakes

The policy, issued by the Centers for Medicare and Medicaid Services, lists eight “hospital-acquired conditions” that will no longer be funded. They were published by the Federal Register on Wednesday in a 1,047-page document.

Medicare officials plan to identify hospital mistakes by comparing the diagnoses listed for patients when they’re admitted with the care they end up receiving. A patient who comes in for routine gall bladder surgery but develops pneumonia and receives additional antibiotics would be a red flag, experts said.

The intent is to make hospitals work like airlines, where they have large financial incentives not to goof up, said Dr. Joseph Scherger, a UCSD family practitioner who specializes in making patient care more safe.

“When the airline industry has delays, it’s costly. They have to buy hotel rooms, put people on different flights, and that takes an enormous amount of agent time,” he said. “For Medicare to say it’s going to align financial incentives to avoid errors is a major statement.”

Patients will be less likely to fall. Surgical wounds will be less likely to get infected. Pressure ulcers will be better prevented and treated. And surgeons will be much less likely to leave sponges or other objects inside bodies.

At least that’s the idea.

“This is clearly a carrot-and-stick approach to make sure hospitals either get rewarded or get dinged when they have negative outcomes,” said Jamie Court, president of the Foundation for Taxpayer and Consumer Rights.

Ahead of the curve

While several San Diego hospital officials declined to comment on the new policy, officials at University of California San Diego and Scripps hospitals were eager to speak. They said they have been working hard for years to incorporate safer practices in their routines, so they don’t think this will have much impact.

“None of this is a surprise, nor will it change what we’re doing every day,” said Dr. Brent Eastman, medical officer for Scripps Health’s five hospitals.

Andrea Snyder, director for UCSD’s performance improvement, added that if organizations are just now making changes to get in step with the new federal regulations, “they are behind the times. We’ve known this was coming.”

Some hospitals have determined how costly mistakes can be.

Scripps staff members calculated that in 2006, mistakes in patient care cost the Scripps system $1.7 million, said Mikele Bunce, Scripps’ director of quality.

Most hospitals have joined national safety organizations’ efforts, such as the “Save Five Million Lives” campaign organized by the Institute for Healthcare Improvement. Five million is the estimated number of medical mistakes a year that cause patients harm, documented by the Institute of Medicine.

In general, the systems involve implementing procedures in which providers would have to go significantly out of their way to make a mistake. Staff members aren’t punished for admitting errors that could be prevented.

Other officials said the new policy does have some problems.

Eastman of Scripps Health suggested that the federal government would have more success if it rewarded hospitals for adopting safeguards and for not making mistakes rather than penalizing them when they do.

Punishment deserved?

Adele Lynch, director of the University of San Diego’s patient advocacy program, said the policy ignores the root cause of medical mistakes: severe underfunding by both government and insurance payers.

“It doesn’t allow them to deliver the kind of care they think they should deliver, and now this will cut them to the bone, penalizing them for something determined to be an acquired complication,” Lynch said.

She added: “People who work in hospitals don’t do their jobs with callous disregard for their patients. Staff are literally running from bed to bed to meet patients’ needs.”

Smaller hospitals may have more trouble implementing the federal policy, several health experts said. “If we have a concern, it’s for those nontertiary care centers who may think twice about taking care of riskier, more complex patients,” said Paul Craig, UCSD’s chief risk and safety officer.

“These are hospitals with thin profit margins already, and they may be unable to bear the additional cost of caring for these patients.”

REIMBURSEMENT RULES

Starting Oct. 1, 2008, the federal government will no longer reimburse hospitals for “hospital-acquired conditions” in eight areas. They are:

– Objects, such as sponges, needles or metal devices, left inside a patient during surgery

– Air embolism, the entry of gas or air through catheters inserted in veins, which can go to the brain or heart

– Incompatible blood transfusion

– Infections from catheters to the urinary tract

– Pressure ulcers or bedsores

– Infections associated with vascular catheters

– Infections after coronary artery bypass surgery

– Falls