Marian Benjamin

In August, CMS passed a new rule stating that beginning October 2008, Medicare will no longer cover errors and other incidents that should not be allowed to occur in a hospital. These include what Medicare calls “never errors”—serious and costly errors in the provision of health care services that should never happen, for example, surgery on the wrong body part or patient—among others. This ruling is part of the IPPS payment reform mandated by the Deficit Reduction Act of 2005.

On the face of it, this ruling seems a sensible step: It could save lives and probably lots of money, too. So, I was surprised when I polled our readers asking whether this rule would be effective in reducing preventable errors, and 61% said no! How can that be? What better way to get hospitals to improve patient care than to hit them where it hurts—in the pocketbook.

The Joint Commission (with its National Patient Safety Goals) and other groups have standards that address patient safety, and hospitals have tried all kinds of strategies to reduce preventable errors, particularly in the area of hygiene—from rewarding staff who follow good hygiene practices to publishing the results of cultures of physicians’ hands. As one of RT‘s advisory board members wrote, “If public humiliation can work, why not try money?”

One problem with the ruling, as another editorial advisory board member wrote to me, is that it might be difficult to sort out which complications arise from lack of proper care and/or technique/prophylaxis and which reflect an adverse event from the illness itself. He was concerned that institutions might refuse care for certain types of conditions that have a frequent association with adverse outcomes, such as patients on prolonged mechanical ventilation, who are at risk for developing VAP.

A spokesperson from the American Hospital Assn questions the impact of the new payment rules and whether they will support hospitals’ efforts to enhance patient safety, saying it is unclear whether some of these conditions are always or even usually preventable.

Editor’s note:
To learn more about hospital infection prevention, check out our December 2005 article, “Hospital Infection Control and Prevention“.

Another problem, and perhaps why 61% of poll participants didn’t think the ruling would be effective: Maybe the ruling does not go far enough. Granted, Medicare will stop paying hospitals to treat eight types of patient injuries that should not occur, but, as Betsy McCaughey, PhD, chair and founder of the Committee to Reduce Infection Rates, points out, the policy omits nearly half of all hospital infections, including most postsurgical infections and infections caused by methicillin-resistant Staphylococcus aureus (MRSA). According to McCaughey, Medicare officials claim that MRSA infections may not be preventable. Wrong, she says, claiming that research has shown that up to 90% of these infections can be prevented through rigorous hygiene; screening incoming patients; and preventing the spread of bacteria on unclean hands, inadequately cleaned equipment, and health care workers’ clothing.

These seemingly simple steps should be practically intuitive, and yet clearly, they are not being followed: Infections are the fourth largest killer in the United States; 2 million patients contract infections in hospitals; and an estimated 103,000 die as a result. A few hospitals that consistently practice good hygiene are proving that infections are almost completely preventable. CMS officials say they will be adding to the list of injuries that hospitals will not be paid to treat; MRSA may be included. Too bad that it may take the hand of CMS to force hospitals to include cleanliness as one of their procedures.

—Marian Benjamin
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