(OAKBROOK, Ill. - February 1, 2008) Although a new Medicare policy to withhold payment for certain hospital errors may lead to some instances of unfairness, an opinion piece in the February 2008 issue of The Joint Commission Journal on Quality and Patient Safety concludes that this "bold experiment" may prompt health care system changes that result in fewer preventable deaths. The Journal is published by Joint Commission Resources (JCR).
The authors of the article-Robert M. Wachter, M.D., professor and associate chair of the Department of Medicine at the University of California, San Francisco; Nancy Foster, vice president for Quality and Safety Policy, American Hospital Association, Chicago; and R. Adams Dudley, M.D., M.B.A., associate professor, Institute of Health Policy Studies, University of California, San Francisco-note that careful monitoring of the consequences of this initiative will be necessary to ensure its effectiveness. Wachter and his colleagues call on Medicare to assess the accuracy of the potentially complex "present on admission" (POA) coding that facilities will use to identify patients who experienced adverse events prior to their hospitalization. The authors also advise Medicare to fund research that helps identify preventable adverse events and develop evidence-based strategies to reduce those adverse events identified as preventable.
The Centers for Medicare & Medicaid Services (CMS) will begin implementing its new policy on October 1, 2008, withholding reimbursement for conditions related to three specific types of hospital-acquired infections, pressure ulcers, retained surgical objects, air embolisms, blood-type incompatibility errors, and hospital injuries including burns and falls. Medicare is also studying expansion of the so-called "not paying for errors" program by adding four other types of hospital-acquired infections and instances of wrong-site surgery.
The Medicare policy is part of numerous nationwide approaches to spur the use of evidence-based improvement strategies by creating a business case for safety and quality. The Journal article notes that while the Medicare policy is intended to improve hospital care, the initiative is likely to mean that the initial eight conditions on the non-reimbursement list will receive extra attention at the
expense of other equally important areas not covered by the policy, such as preventable medication, transitional, or diagnostic errors. Wachter and the other authors emphasize the need for validated, standardized definitions of the conditions that lead to withholding payments, noting that vague definitions may lead to "gaming" by hospitals and not result in true patient safety improvement.
"Among the variety of strategies implemented in American hospitals, the Medicare policy may have a beneficial effect on patient safety, provided that adverse events can be accurately measured and are clinically significant" says Wachter. "The policy must be carefully monitored and also foster a culture of safety that is the backbone to quality and safety efforts."
Wachter and his colleagues point out that the new policy does not differentiate between trivial and significant harm, which may be an important distinction as new conditions are added over time. Although the authors conclude that the new policy may be effective, the authors believe that the reimbursement dollars at risk for most hospitals will be "fairly small because most of the adverse events on the list are unusual and because patients with any complicating conditions often have more than one (on which case hospitals will still receive their extra payments, even if one of the conditions in on the ‘no pay' list)."
The Joint Commission Journal on Quality and Patient Safety, published monthly by Joint Commission Resources, features peer-reviewed research and case studies on improving quality and safety in health care organizations. To subscribe to The Joint Commission Journal on Quality and Patient Safety, please call JCR Customer Service toll-free at 800.746.6578, or visit www.jcrinc.com.