R.Ph.s brace for payment denial for hospital-acquired conditions

October 22, 2007

CMS will soon be denying reimbursement for certain hospital-acquired conditions, according to new rules published this year.

CMS has adopted a handful of events from a list endorsed by the National Quality Forum. In 2002, NQF endorsed a list of 27 serious adverse healthcare events that are preventable and of significant concern to healthcare providers and patients. Several of these events, CMS has determined, are clearly preventable. Therefore, effective Oct. 1, 2008, CMS will not pay hospitals for additional costs incurred by any of the following conditions occurring after admission: pressure ulcers, blood incompatibility, air embolisms, objects inadvertently left in patients during surgery, hospital-acquired injuries (burns, fractures, dislocations), catheter-associated infections (urinary and vascular catheters), and infections associated with coronary artery bypass graft surgery.

Minnesota hospitals are taking reform one step further. On Sept. 18, Gov. Tim Pawlenty announced hospitals will not bill patients or their insurers for any of NQF's 27 types of preventable adverse health events. "It seems obvious to us, but Minnesota is the first state in the nation to agree that patients, employers, and insurers shouldn't pay for care made necessary by an adverse health event," Pawlenty said.

Although Massachusetts does not have a similar law, just over half of the state's hospitals have adopted the policy of not charging patients or their insurers for errors. According to Leapfrog Group, 33 of the state's 61 hospitals have voluntarily ceased charging for any of the preventable events on NQF's list. Other hospitals in the state may soon follow suit.

The new rules taking effect nationally and in individual states will require hospitals to make changes. First and foremost, hospitals must be sure all primary and secondary diagnoses are noted upon admission. A diagnosis made after admission may result in nonpayment.

With new challenges come opportunities for improvement, but "there's always the potential for untoward consequences," Thompson said. For example, it's possible that in order to prevent infection, too many patients could be put on unnecessary prophylactic antibiotics.

"The value of the pharmacist in these programs is significant," he said. Monitoring appropriate antibiotic use will be a key function health-system R.Ph.s can perform.

Checking it twice

Although medication errors can cause significant harm, this preventable occurrence is notably missing from CMS' list. That's probably because there is no code yet for medication errors, said Michael D. Sanborn, B.S., M.S., corporate director of pharmacy for Baylor Healthcare System, Dallas. With all the evidence available on injuries caused by medication errors, Sanborn believes it's only a matter of time before payers deny payment for this type of injury as well.

Meanwhile, health-system R.Ph.s can help prevent HACs in many ways. "One big thing is hand washing," said Sanborn. Pharmacists should be sure they and everyone with patient contact are practicing good infection control measures. Pharmacists should also participate in fall committees, he said, because they can help identify drugs and other hazards that make patients more susceptible to falls.