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Medicare takes stance: will not pay for 'errors'

As a way to prevent unnecessary illnesses and preventable infections in patients during hospital stays, the Centers for Medicare and Medicaid Services (CMS) will no longer be covering the extra costs of a patient’s prolonged stay in a hospital if the patient’s condition could have been prevented by following proper care and cleanliness standards.

According to Health Insurance Counseling Advocacy program director David Weil, the cut is a measure Medicare is using to make hospitals responsible for “never events,” a term used by medical professionals for events that are never supposed to happen to patients under a hospital’s care.

The decision, which was made possible because of the Deficit Reduction Act of 2005, was put into full effect October 1 of this year.

Conditions that will no longer be covered by CMS include mediastinitis after a coronary artery bypass graft surgery, bed sores, air embolism, falls, leaving objects inside the patient during surgery and vascular catheter-associated urinary tract infections, but the main impact of CMS’ cuts will be the way patients are treated so they do not contract hospital-acquired infections.

When a patient enters a hospital for treatment, an initial diagnosis is made to decide whether or not the patient will require a prolonged hospital stay because of a high-risk procedure or illness. A report is sent to CMS, which then pays the hospital a bulk sum for the patient’s treatment and hospital stay. If the patient does not need a prolonged stay in the hospital, CMS pays less than it would if the patient were under the hospital’s care for a longer period of time.

According to Ellen Griffith, a CMS representative, when an efficiently run hospital receives the single bundled payment for a patient’s treatment, it can make a margin of profit on each Medicare patient treated, regardless of the amount of time the patient spent in the hospital.

If after a required secondary diagnosis is done on the patient and an infection, bed sores or another type of preventable illness is discovered, the hospital will have to absorb the additional costs of the stay, which were normally covered by Medicare before, as if it were a regular prolonged hospital stay.

Griffith calls the payment reduction a “small but efficient” cut, as it will save Medicare about $21 million out of the estimated $110 billion paid to hospitals to cover patient hospital stays for the 2009 financial period.

The cut will also make hospitals responsible for any “bubble effects” of the infection, such as follow-up treatment and medication needed after being released from the hospital.

Medicare’s patients do not have to worry about being charged with the difference hospitals have to absorb, said Griffith, as it would be illegal for the hospitals to try to charge their patients with the fee.

Each hospital is responsible for its cleanliness and sanitation procedures, said Jan Emerson, a representative with the California Hospital Association.

Each hospital has quality standard officials, and they will be the ones who need to make sure that the hospital is kept clean and maintains high patient treatment standard, she said.

The new procedure is an incentive for hospitals to properly diagnose all of the patients’ illnesses as they are admitted for treatment, so that they are able to receive a larger amount of money for having a patient who needs a longer stay, said Griffith.

But the new procedure also expects that the hospitals treat their short-term patients with just as much care, and hospitals will be penalized if all patients do not receive proper treatment, she said.

There are more than 200,000 needless deaths per year because of poor medical treatment in hospitals, said Weil.

“This is just a way Medicare is motivating hospitals to improve the care given to their patents,” said Weil, “as well as making hospitals responsible for any bad medical outcomes that could easily be prevented.”

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