|Implemented in this survey?|
As of October 2008, Medicare no longer pays hospitals for costs associated with treatment complications for certain conditions that could have been avoided if proper quality improvement procedures were in place. Since the policy change took effect, Medicare has gone even further - adding additional conditions to the list, and extending the policy to include physician payments in the case of certain preventable errors.
The Centers for Medicare and Medicaid Services (CMS) initially introduced a policy in September of 2008 to improve the quality of care that patients receive in the hospital setting and to reduce Medicare expenditures associated with the treatment of preventable errors, injuries and infections. By shifting the cost of medical errors onto hospitals, it was thought that hospital staff would have an increased incentive to improve the quality of care.
Despite objections from some hospital leaders and physicians over the original policy, CMS decided to expand its list of conditions deemed "reasonably preventable" in late 2008 to include 9 additional conditions: surgical site infections associated with elective procedures, Legionnaires disease, poor glycemic control, iatrogenic pneumothorax, delerium, ventilator-associated pneumonia, deep vein thrombosis/pulmonary embolism, staphylococcus aureus septicemia and clostridium difficile-associated disease. In addition, in early 2009, CMS announced its intention to stop all payments to hospitals and physicians for three so-called 'never events': surgery on the wrong patient, the wrong surgical procedure and surgery on the wrong body part.
|Medienpräsenz||sehr gering||sehr hoch|
The program is just being implemented and so far has had little impact. The impact will occur as the list of conditions expands.
|Implemented in this survey?|
Stakeholder positions on CMS' policy have largely remained the same. Physicians and hospital leaders still support the concept of quality improvement, but continue to argue that Medicare's policy of non-payment for certain conditions creates a punitive environment that perpetuates blame and secrecy. Moreover, the position of hospital leaders and providers has grown more nuanced over time: while providers largely agree with a policy of non-payment for certain errors (particularly wrong person, wrong surgery and wrong site errors), they argue that other errors, such as hospital acquired infections (HAIs), are less clearly preventable. In addition, some argue that CMS' policy may change individual physician behavior, but without system-level changes in the culture and organization of services, non-payment has limitations in creating incentives for improved quality.
|The Centers for Medicare and Medicaid Services||sehr unterstützend||stark dagegen|
|Hospitals||sehr unterstützend||stark dagegen|
|Physicians||sehr unterstützend||stark dagegen|
|Private health insurance companies||sehr unterstützend||stark dagegen|
|Medicare beneficiaries||sehr unterstützend||stark dagegen|
The original policy went into effect on October 1, 2008. In late 2008, CMS expanded the policy so that beginning in 2009, 9 additional conditions deemed "reasonably preventable" would also no longer be reimbursed by Medicare. These conditions include surgical site infections associated with elective procedures, Legionnaires disease, poor glycemic control, iatrogenic pneumothorax, delerium, ventilator-associated pneumonia, deep vein thrombosis/pulmonary embolism, staphylococcus aureus septicemia and clostridium difficile-associated disease.
In early 2009, CMS announced its intention to stop all payments in cases of surgery on the wrong patient, the wrong surgical procedure and surgery on the wrong body part.
|The Centers for Medicare and Medicaid Services||sehr groß||kein|
|Private health insurance companies||sehr groß||kein|
|Medicare beneficiaries||sehr groß||kein|
Hospitals and providers have been highly affected by the implementation of this policy. In order to receive payment, providers must evaluate and report conditions are 'present-on-admission', so new efforts to collect data prior to the admission of a patient have been implemented. "Present on admission" conditions are not part of the payment policy and would be reimbursed by Medicare. However, providers argue that the ability of hospital staff to diagnose and report 'present-on-admission' conditions is limited and can be time-consuming.
Alongside non-payment policy, CMS added new quality reporting requirements and expanded the list of quality measures for which hospitals must report data in order to receive a full annual payment update. This, together with Medicare expenditure data and claims data, will help in the monitoring and evaluation of the policy. To date, no impact assessment has been published. Preliminary estimates suggest that few hospitals will be penalized initially because the events that are targeted occur rarely. However, as the list expands the penalities could become more severe.
CMS has continued to expand its policy on non-payment of preventable complications. Although the overall reduction in Medicare payments to hospitals as a result of the policy has been estimated at just 0.01 percent nationwide, other potential by-products of the policy continue to worry stakeholders. Particularly prominent are concerns that non-payment for errors that truly are not preventable could further reduce provider buy-in and could potentially result in decreased access to care for patients whom doctors perceive to be at high risk for complications.
The main concerns arise as the list expands.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
Despite ongoing concerns voiced by providers, the Centers for Medicare and Medicaid Services believe strongly in this policy. This policy continues to have the potential to significantly reduce the occurrence of preventable medical errors and to improve quality of care.
Centers for Medicare and Medicaid Services Press Release. CMS Proposes to Expand Quality Program for Hospital Inpatient Services in FY 2009. April 14, 2008. Available at: http://www.cms.hhs.gov/apps/media/press/release
Mattie AS, and B.L. Webster. Centers for Medicare and Medicaid Services' "Never Events": An Analysis and Recommendations to Hospitals. The Health Care Manager. (27) 4: 338-349. October/December 2008.
Milstein A. Ending Extra Payment for "Never Events" - Stronger Incentives for Patients' Safety. New England Journal of Medicine. (360) 23: 2388-2390. June 4, 2009.
Pronovost P, Goeschel CA, and R.M. Wachter. The Wisdom and Justice of Not Paying for "Preventable Complications". JAMA. (299) 18: 2197-2199. May 14, 2008.
Emily Adrion and Gerard Anderson