Medicare proposal would refuse payment for complications

Tuesday, April 15, 2008

WASHINGTON -- Federal health officials on Monday proposed adding dangerous blood clots in the leg and eight other conditions to the list of complications that Medicare won't pay to treat if they were acquired at the hospital.

Medicare set a new precedent last year by saying it would no longer pay hospitals for treating certain "never events" -- conditions that occur as a result of hospital error. For example, if a patient were given the wrong blood type, Medicare would not pay the hospital more for the subsequent care a patient required. Originally, eight conditions were covered under the new rules, which take effect Oct. 1.

The rules proposed Monday add nine conditions, including:

* Deep vein thrombosis, or a blood clot within the vascular system, which occurred in 140,010 cases for the fiscal year ending Sept. 30.

* Ventilator-associated pneumonia, which occurred in 30,867 cases.

* Bloodstream infections with the staph aureus bacteria, 27,737 cases.

* Legionnaire's disease, which occurred in 351 cases.

Medicare's policy often sets precedent for private insurers, and many of them have already begun to adopt their own never-event policies.

The government estimates the proposed rule will save Medicare an estimated $50 million annually during each of the next three years.

In its 1999 report, "To Err is Human: Building a Safer Health System," the Institute of Medicine concluded that medical errors, particularly hospital-acquired conditions, may be responsible for as many as 98,000 deaths annually.

The proposed rule would apply to more than 3,500 acute care hospitals. Medicare gives hospitals a single payment based on the average cost of treating a patient with a particular diagnosis. Officials said hospitals cannot try to charge the patient for the costs associated with treating a never event.

Congress in 2006 gave the Centers for Medicare and Medicaid Services power to prevent higher payments for the extra costs of treating infections and other preventable conditions that occur during a hospital stay.

Under the government's reimbursement policy, hospitals are also required to report on 30 measures designed to assess quality of care. Medicare is proposing to add 43 new measures to the list. If hospitals don't report the measures, then they don't quality for a full update in their reimbursement rates.

Medicare uses the information from the quality measures when assessing the performance of hospitals. It places the information on the agency's Web site to help consumers compare the health care delivered at their local hospitals.

On the Net

* Centers for Medicare and Medicaid Services: www.cms.hhs.gov

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