Article

Potential Unintended Consequences Due to Medicare’s “No Pay for Errors Rule”? A Randomized Controlled Trial of an Educational Intervention with Internal Medicine Residents

Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, CA 94143, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 10/2010; 25(10):1097-101. DOI: 10.1007/s11606-010-1395-9
Source: PubMed

ABSTRACT Medicare has selected 10 hospital-acquired conditions for which it will not reimburse hospitals unless the condition was documented as "present on admission." This "no pay for errors" rule may have a profound effect on the clinical practice of physicians.
To determine how physicians might change their behavior after learning about the Medicare rule.
We conducted a randomized trial of a brief educational intervention embedded in an online survey, using clinical vignettes to estimate behavioral changes.
At a university-based internal medicine residency program, 168 internal medicine residents were eligible to participate.
Residents were randomized to receive a one-page description of Medicare's "no pay for errors" rule with pre-vignette reminders (intervention group) or no information (control group). Residents responded to five clinical vignettes in which "no pay for errors" conditions might be present on admission.
Primary outcome was selection of the single most clinically appropriate option from three clinical practice choices presented for each clinical vignette.
Survey administered from December 2008 to March 2009. There were 119 responses (71%). In four of five vignettes, the intervention group was less likely to select the most clinically appropriate response. This was statistically significant in two of the cases. Most residents were aware of the rule but not its impact and specifics. Residents acknowledged responsibility to know Medicare documentation rules but felt poorly trained to do so. Residents educated about the Medicare's "no pay for errors" were less likely to select the most clinically appropriate responses to clinical vignettes. Such choices, if implemented in practice, have the potential for causing patient harm through unnecessary tests, procedures, and other interventions.

0 Followers
 · 
143 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In 2008, the Centers for Medicare & Medicaid Services introduced a new policy to adjust payment to hospitals for health care-associated infections (HAIs) not present on admission. Interviews with 36 hospital infection preventionists across the United States explored the perspectives of these key stakeholders on the potential unintended consequences of the current policy. Responses were analyzed using an iterative coding process where themes were developed from the data. Participants' descriptions of unintended impacts of the policy centered around three themes. Results suggest the policy has focused more attention on targeted HAIs and has affected hospital staff; relatively fewer systems changes have ensued. Some consequences of the policy, such as infection preventionists having less time to devote to HAIs other than those in the policy or having less time to implement prevention activities, may have undesirable effects on HAI rates if hospitals do not recognize and react to potential time and resource gaps.
    Medical Care Research and Review 08/2011; 69(1):45-61. DOI:10.1177/1077558711413606 · 2.57 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Many people living with chronic conditions have multiple chronic conditions. Multimorbidity is defined here as the co-existence of two or more chronic conditions, where one is not necessarily more central than the others. Multimorbidity affects quality of life, ability to work and employability, disability and mortality. Currently, clinicians have limited guidance or evidence as to how to approach care decisions for such patients. Understanding how to best care and design the health system for patients with multimorbidity may lead to improvements in quality of life, utilization of healthcare, safety, morbidity and mortality. The objective of this paper is to review the implications of multimorbidity for the design of health system and to understand the research needs for this population. The consideration of people with multimorbidity is essential in the design and evaluation of health systems. Fundamentally, people with multimorbidity should receive a patient -and family-centered approach to care throughout the health system, and understanding how to deliver this type of care in effective and efficient ways is an enormous challenge, and opportunity, for clinicians, researchers, and policy makers today.
    Public health reviews 01/2010; 32:451-474.
  • [Show abstract] [Hide abstract]
    ABSTRACT: To test the accuracy of reporting present-on-admission (POA) and to assess whether POA reporting accuracy differs by hospital characteristics. We performed an audit of POA reporting of secondary diagnoses in 1,059 medical records from 48 California hospitals. We used patient discharge data (PDD) to select records with secondary diagnoses that are powerful predictors of mortality and could potentially represent comorbidities or complications among patients who either had a primary procedure of a percutaneous transluminal coronary angioplasty or a primary diagnosis of acute myocardial infarction, community-acquired pneumonia, or congestive heart failure. We modeled the relationship between secondary diagnoses POA reporting accuracy (over-reporting and under-reporting) and hospital characteristics. We created a gold standard from blind reabstraction of the medical records and compared the accuracy of the PDD against the gold standard. The PDD and gold standard agreed on POA reporting in 74.3 percent of records, with 13.7 percent over-reporting and 11.9 percent under-reporting. For-profit hospitals tended to overcode secondary diagnoses as present on admission (odds ratios [OR] 1.96; 95 percent confidence interval [CI] 1.11, 3.44), whereas teaching hospitals tended to undercode secondary diagnoses as present on admission (OR 2.61; 95 percent CI 1.36, 5.03). POA reporting of secondary diagnoses is moderately accurate but varies by hospitals. Steps should be taken to improve POA reporting accuracy before using POA in hospital assessments tied to payments.
    Health Services Research 12/2011; 46(6pt1):1946-62. DOI:10.1111/j.1475-6773.2011.01300.x · 2.49 Impact Factor

Preview (2 Sources)

Download
0 Downloads
Available from