While on vacation, I did view a few blogs. One topic which caught my eye was the new Medicare policy on errors. Today’s WSJ has an interesting piece on this topic – Hospitals Combat Dangerous Bedsores

Dr. RW posted an excellent thought piece on this issue – What will be the consequences, intended and unintended, of the new Medicare coding rules for adverse events in hospitalized patients?

At this risk of redundancy, I will add my opinion. As the WSJ article points out:

That is changing with the advent of Medicare’s new payment policy, which some private insurers are considering following. In addition to pressure ulcers, the preventable conditions for which Medicare will no longer reimburse hospitals include injuries from patient falls, urinary-tract infections, vascular-catheter-associated infections and mediastinitis, an infection following heart surgery. Also included are so-called never events, meaning they never should happen: objects left in the body during surgery, air embolisms and blood incompatibility. Medicare plans to add three additional conditions next year.

Let us consider each issue. While we should be able to decrease the number of pressure ulcers, I doubt that we can prevent them entirely. The WSJ article points out the lengths that hospitals are taking to try and prevent such ulcers.

Next we must consider patient falls. I know that we try very hard to prevent falls, but one cannot have a perfect record here. As RW states, we could prevent falls by tying patients down, but that would probably increase pressure ulcers. And patient advocates would criticize us for the use of restraints. We need to study falls, and work to minimize them.

Third is (in my mind) the most outrageous – urinary tract infections. Now I suspect that they want us to limit use of indwelling urinary catheters. That is laudable goal. But some patients have strong indications for indwelling urinary catheters. For example, you admit a man with urinary retention secondary to BPH. This patient needs an indwelling urinary catheter. A percentage of such patients will develop a urinary tract infection. This is a known side effect, which is probably not preventable. Now CMS will penalize hospitals who care for urological patients.

Fourth is less egregious – vascular-catheter-associated infections. We should be able to minimize these infections. However, some infections will occur, even with best practices.

The remaining “never should happen” errors are reasonable.

CMS has a reasonable idea, they need to tweak their methods. What we really want to do is decrease the rates of falls, pressure ulcers, urinary tract infections and vascular catheter infections. They should come up with an acceptable rate for these complications. Challenge hospitals to install processes to do better than an acceptable baseline rate. Penalize hospitals who (in consecutive quarters) have unacceptable rates on at least 2 of these indicators.

As often happens with bureaucracy, the designers of this concept start out with a reasonable thought, but do not spend enough time working through the consequences of rule development. But then I suspect that few observers are surprised.