Printer-friendly format

In October, the Centers for Medicare and Medicaid Services (CMS) issued stringent guidelines on exclusion of reimbursement for eight hospital acquired conditions (HAC) that were not present at the time of admission, and added five more to the list December 1. These conditions include foreign objects retained after surgery, air embolism, blood incompatibility, pressure ulcers, falls and trauma, catheter associated UTI, vascular catheter associated infections, and infections after coronary artery bypass grafts. The additional five added to the list this month include surgical site infections after elective procedures, poor control of blood sugar levels, and deep vein thrombosis or pulmonary embolism following knee and hip replacements.

Ultimately this move reflects a general shift toward improved quality and safety in the healthcare industry as mandated under the Deficit Reduction Act of 2005. Experts explain these conditions were chosen not only due to high volume and high cost, but particularly with the infections, there are already national, evidence-based guidelines for reducing incidence. While adhering to strict safety guidelines is nothing new for hospitals, the HAC reimbursement rules have required additional system modifications.

"We already had steps in place for many years to address most of these conditions. (The mandate) wasn't a surprise for us, but we did have to adjust," said Richard Drewry, MD vice president and chief medical officer of Baptist Memorial Health Care. "We stepped up our documentation because we have to know whether it was present-on-admission and if it occurred during hospitalization, when did it occur?"

He continued, "We've increased our alertness for high risk patients for these conditions when they come in."

The National Conference on State Legislatures (NCSL) reports the rate of growth of healthcare costs has made it necessary to examine every avenue available to conserve healthcare dollars. According to the Congressional Budget Office (CBO) without any changes to federal law, total spending on health care will rise from 16 percent of the gross domestic product (GDP) in 2007 to 25 percent in 2025 and 49 percent in 2082, and net federal spending on Medicare and Medicaid will rise from four percent of the GDP to almost 20 percent over the same period. The Institute of Medicine has estimated that medical errors cost $17 billion to $29 billion per year with most of the cost being shifted to outside payers such as Medicare.

The rational for the use of present-on-admission (POA) indicators according to the Healthcare Cost and Utilization Project (H-CUP) is that it will distinguish pre-existing conditions from complications and help to improve the design and fairness of pay-for-performance programs. CMS estimates the federal government will realize savings of $50 million per year for the first three years beginning October 1, 2008. Beginning in fiscal year 2012, they estimate savings of $60 million per year.

"Any time something this significant happens within the industry, we do go back and review all of our processes," explained Beverly Jordan, vice president and chief nursing officer for Baptists Memorial Health Care.

At Baptist, a webinar was conducted for all 15 hospitals that included CEOs, CFOs, CNOs, and other clinical leaders and key physician leaders in each of their facilities. Explained Jordan, "We all understood the role of CMS, the conditions, how we can detect them, how we can avoid them, how we can work with the medical staff to assist them with accurate timely documentation."

To keep the process streamlined, an educational module was written, Jordan said, targeted toward any employees who would have contact with the patients, and was put on the intranet site. Employees can work through that educational module and answer questions in a post test format.

"Concurrently, each hospital identified a key contact that anybody can call with any question about any aspect of this new initiative," added Jordan. "If someone has a question about documentation or whether it's present on admission or not, they have a person in every facility they can call."

Another change coming with the HAC rules is physicians not having to do the documentation in the medical records. What hasn't changed is being vigilant about collecting and studying data, but "we have put these other efforts on top of it to make sure we are all working in this arena in a synergistic manner," said Jordan. "We're always going to be emphasizing consistency and how we practice and how we treat patients."

The biggest area for debate with the CMS rules is the zero percent clause. CMS expects certain conditions like UTIs and pressure ulcers to be at zero. Drewry said that while the hospital staff shoots for that, it is unrealistic to hold down a zero standard.

"The fact is that we, as an industry, can certainly do better by paying close attention to these (conditions)," he said.

The use of automation has been helpful in some cases, such as with tether alarms for patients at high risk for falls, silver tipped catheters to prevent infection as part of various evidence-based bundle systems, and even automation sensors to prevent objects retained during surgery. But, Jordan maintained, "Technology will never replace people or processes; it has to be a combination of all three things being constructed to work together to improve all outcomes."

"We embrace the opportunity to look at this because while zero is that number out there, we're going to continue to look at anything the evidence supports that can help us do it better and more consistently for every patient," she added.

Overall the quality paradigm shift is steadily gaining momentum, and healthcare professionals are expecting the trend to continue.

"I don't think it's a surprise that CMS will add a lot more or that the commercial carriers are going to follow suit," Drewry said.

Added Jordan, "The thing about healthcare today that is very different from years past is that healthcare – hospitals, health systems, all of our other partners – are trying to share things with us, things that work or things they tried that didn't work. Instead of everybody working in isolation, we're really trying to tackle the safety and quality issues together."

Tags:

Centers for Medicare and Medicaid Services, Deficit Reduction Act of 2005

Login and voice your opinion!