Medicare's Decision to Withhold Payment for Hospital Errors: The Devil Is in the Details
BACKGROUND: Medicare recently announced its intention to withhold additional payments for "serious preventable events." THE INTERVENTION: Beginning in 2009, Medicare will withhold its usual additional payments associated with hospitalizations that included one of several potentially preventable adverse events, such as certain hospital-acquired infections, pressure ulcers, and retained surgical objects. Several more events are being considered for the future. A new coding category, "present on admission" (POA), has been added to identify patients whose adverse events occurred before the index hospitalization. ISSUES AND CHALLENGES: A "not paying for errors" policy seems reasonable if evidence demonstrates that most of the adverse events can be prevented by widespread adoption of achievable practices, the events can be measured accurately, the events resulted in clinically significant patient harm, and POA determination is feasible. Many of these criteria are met for the events in Medicare's starter set; but there are concerns about each event. CONCLUSIONS: Although the new Medicare policy will undoubtedly lead to instances of unfairness, gaming, and unforeseen consequences, it may be effective. This initial implementation should be considered a bold experiment, whose consequences are carefully monitored. Additional research will be needed to help identify preventable adverse events and evidence-based strategies to prevent them.
Available from: Mathias Worni
- "The majority of patients eligible for Medicare are older than age 65, and VTE risk varies considerably by age , so patients younger than age 65 were excluded when developing parameters for the model. Typical Medicare reimbursement to hospitals is $10,000, $13,000 for patients with a major comorbidity or those who experience a complication . The rationale for implementing the HACS were the low rates of guideline-recommended proplylaxis . "
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ABSTRACT: The Hospital Acquired Condition Strategy (HACS) denies payment for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The intention is to reduce complications and associated costs, while improving the quality of care by mandating VTE prophylaxis. We applied a system dynamics model to estimate the impact of HACS on VTE rates, and potential unintended consequences such as increased rates of bleeding and infection and decreased access for patients who might benefit from TKA.
The system dynamics model uses a series of patient stocks including the number needing TKA, deemed ineligible, receiving TKA, and harmed due to surgical complication. The flow of patients between stocks is determined by a series of causal elements such as rates of exclusion, surgery and complications. The number of patients harmed due to VTE, bleeding or exclusion were modeled by year by comparing patient stocks that results in scenarios with and without HACS. The percentage of TKA patients experiencing VTE decreased approximately 3-fold with HACS. This decrease in VTE was offset by an increased rate of bleeding and infection. Moreover, results from the model suggest HACS could exclude 1.5% or half a million patients who might benefit from knee replacement through 2020.
System dynamics modeling indicates HACS will have the intended consequence of reducing VTE rates. However, an unintended consequence of the policy might be increased potential harm resulting from over administration of prophylaxis, as well as exclusion of a large population of patients who might benefit from TKA.
- "Stock, Drabik et al. 2010) and some P4P chronic disease outcome measures are potentially highly costeffective (Walker, Mason et al. 2010). Expenditure may be reduced by lowering the incidence of avoidable complications in hospitals, such as by refusing to reimburse providers for specified " never events " such as wrong-limb surgery, referred to as non-payment for performance (Rosenthal 2007; Wise 2009), although in practice such financial savings may be negligible due to the rarity of these events (Wachter, Foster et al. 2008). Moreover, providers may be paid on the basis of efficiency measures such as the quality-adjusted cost per episode, and P4P can seek to lower costs by incentivising reduced rates of hospital readmissions, although assigning financial risk for readmissions can be challenging. "
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ABSTRACT: Ireland’s health system is at a key turning point. The Irish government was newly elected in February 2011, and the policy directions adopted over the coming months will likely exert a major impact on system performance for many years. Drawing on recent international experience with performance measurement and financial incentives, this paper examines strategies for enhancing quality and value in the Irish health system, focusing predominantly on the role of primary care.Three take-home messages emerge from the literature. First, substantial improvements in quality of care often can be attained at a reasonable cost, such as through the use of checklists and evidence-based clinical pathways, or by better aligning the skills of health care providers to patients’ need. Second, rigorous performance measurement is a vital tool for quality improvement that is lacking in Ireland, and this could be particularly powerful if underpinned by risk-adjustment to enable reliable evaluation of clinical outcomes. Pilot projects are required to examine the feasibility of these techniques in the Irish context. Third, although pay-for-performance is a prominent quality improvement strategy, little evidence exists to support its purported benefits and it can exert negative effects. Incentives are unlikely to be effective if providers lack the capability to respond appropriately, therefore it is imperative to foster professionalism and pride in high-quality care, and to develop the managerial and clinical skills necessary for high performance.
Available from: PubMed Central
- "This phenomenon has been described in other large health systems changes, such as the implementation of the “time to antibiotics for pneumonia” performance measure, which may result in the inappropriate early use of antibiotics in an attempt to excel on a performance measure11–13. Similarly, the physician response to the new “no pay for errors” rules could have major consequences, both intended and unintended14,15. Our study supports concerns that giving clinicians information regarding “no pay for errors” and other reimbursement rules may lead to unintended consequences with the potential to harm patient care unless such education balances individual patient needs with a more systems and reimbursement-based emphasis. "
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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.
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