Managed Care - May 2008 - (Page 30) adopted in 1983, but there are 207 additional DRGs and the new subclass Changes in Medicare payments designation “major complication or linked to quality of care comorbidity,” an example of which is Beginning Oct. 1, Medicare will no longer pay for eight hospital-acquired severe sepsis. medical conditions, five of which are “serious reportable adverse events” “It is a far less passive system,” says as determined by the National Quality Forum. Here is a list of those HACs, Meredith Rosenthal, PhD, an associtheir frequency and cost in 2007, and where evidence-based guidelines are ate professor of health economics and available addressing their prevention. policy at the Harvard School of PubCMS will not pay for these hospital-acquired conditions lic Health. The actuarial consulting company Number of cases and cost per hospital stay Selected hospital acquired condition (HAC) Milliman Inc. recently published a in FY2007 Selected evidence-based guidelines study of the effect of the changes on Foreign object retained after surgery 750/$63,631 health plans and hospitals. Calling http://www.ahrq.gov/qual/nqfpract.htm MS-DRG “the most significant revision to Medicare inpatient payment Air embolism 57/$71,636 http://www.ahrq.gov/qual/nqfpract.htm methods” in more than a quarter century,” the report states that the finanBlood Incompatibility 24/$50,455 http://www.ahrq.gov/qual/nqfpract.htm cial effect on health plans and hospitals will result from the degree of Stage III & IV pressure ulcers 257,412/$43,180 change in the “related weights” used as http://www.ncbi.nlm.nih.gov/books/bv.fcgi? rid=hstat2.chapter.4409 a basis for payment: “Although the overall effect on the Medicare proFalls and trauma: 193,566/$33,894 • Fractures gram is intended to be cost-neutral, • Dislocations the substantial changes in payment • Intracranial injuries levels for individual cases will result in • Crushing injuries significant changes to the total • Burns amount of Medicare inpatient pay• Electric shock ments received It would be a mishttp://www.ahrq.gov/qual/nqfpract.htm take to assume that the changes will Catheter-associated urinary tract infection (UTI) 12,185/$44,043 average out.” http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html According to the Milliman analysis, Vascular catheter-associated infection 29,536/$103,027 under this new system, payment for http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html some individual admissions will inSurgical site infection — Mediastinitis after 69/$299,237 crease by as much as 20 percent. The coronary artery bypass graft (CABG) report states that a few hospitals, such http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html as acute-care facilities treating the Source: Centers for Medicare & Medicaid Services sickest patients, including some specialty hospitals, may see their Medicare payments double. in hospital contracts that it will no longer pay nor The original payment DRG system, known as let patients be billed for the National Quality CMS-DRG, was adopted in 1983 as a prospective Forum’s 28 “never events,” incidents so egregious system. Payments to hospitals were made based on they should never occur. admission diagnosis. But that system was “never The overall effect of MS-DRG goes beyond what completely prospective,” says Rosenthal. CMS won’t pay for — it changes the manner in In an article in the October 2007 issue of the New which payments are evaluated and weighed. MSDRG has 25 major disease categories, 745 diagnoEngland Journal of Medicine, Rosenthal points out sis-related groups, and three subclasses of complithat CMS-DRG payments were adjusted for pacations and comorbidities. That is the same number tients who developed complications after admisof major disease categories as the original system, sion, and CMS made “outlier payments that par- 30 MANAGED CARE / MAY 2008 http://www.ahrq.gov/qual/nqfpract.htm http://www.ahrq.gov/qual/nqfpract.htm http://www.ahrq.gov/qual/nqfpract.htm http://www.ncbi.nlm.nih.gov/books/bv.fcgi http://www.ahrq.gov/qual/nqfpract.htm http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html
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