Managed Care - May 2008 - (Page 35) tially compensated hospitals for additional expenses incurred.” Perverse incentive “With regard to preventable complications, these retrospective features of the DRG payment system have harbored a perverse incentive: Hospitals that improved patient safety and ameliorated problems such as nosocomial infections saw their Medicare revenues — and sometimes their profits — reduced,” wrote Rosenthal. Reform to address this flaw in the prospective system of payment began with the Deficit Reduction Act of 2005, which was the federal product of the marriage of quality and cost control that began in the early 1990s. The act’s stated purpose was to reduce overall hospital costs by improving care: Congress ordered CMS to select at least two conditions that the agency considered costly or too frequent, that resulted in the assignment of patients to a higher-paying DRG when they have that condition as a secondary diagnosis after admission, and that could have been prevented through adherence to evidence-based guidelines. Bigger changes ahead The total financial effect of MSDRG on each health system will depend on total patient mix. “Our initial estimates suggest that the net change in total Medicare payments will be 5 percent or less for most hospitals,” the report says. That’s the good news, but as always the devil is in the details. According to the report, the bottom line is that about 60 percent of hospitals will see a drop in Medicare payments — and some could lose as much as 30 percent of their Medicare payment. The effect of the shift in how CMS weighs its Medicare payments — and the attendant adjustment in software Nine more conditions proposed for payment exclusion On April 14, CMS announced an expansion of the conditions listed on the chart on page 30. The following conditions are now proposed. Following a public comment period, they could also be adopted for implementation by this October. Proposed hospital-acquired conditions ineligible for payment HAC candidate Selected evidence-based guidelines Medicare data (FY 2007) Surgical site infections following elective procedures: • Total knee replacement • Laparoscopic gastric bypass and gastroenterostomy • Ligation and stripping of varicose veins http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html http://www.cdc.gov/ncidod/dhqp/gl_isolation.html 539 cases/$63,135 208 cases/$180,142 3 cases/$66,355 Legionnaires’ Disease http://www.cdc.gov/ncidod/dbmd/diseaseinfo/ legionellosis_g.htm http://www.legionella.org/ 351 cases/$86,014 Glycemic control: • Diabetic ketoacidosis • Nonketotic hyperosmolar coma • Diabetic coma • Hypoglycemic coma http://www.diabetes.org/uedocuments/ InpatientDMGlycemicControlPositionStmt02.01.06.REV.pdf 11,469 cases/$42,974 3,248 cases/$35,215 1,131 cases/$45,989 212 cases/$36,581 Iatrogenic Pneumothorax http://www.ncbi.nlm.nih.gov/pubmed/1485006 22,665 cases/$75,089 480 cases/$23,290 30,867 cases/$135,795 140,010 cases/$50,937 Delirium http://www.ahrq.gov/clinic/ptsafety/chap28.htm Ventilator-associated pneumonia (VAP) http://www.rcjournal.com/cpgs/09.03.0869.html Deep vein thrombosis (DVT)/pulmonary embolism (PE) http://www.chestjournal.org/cgi/reprint/126/3_suppl/172S http://orthoinfo.aaos.org/topic.cfm?topic=A00219 Staphylococcus aureus septicemia http://www.cdc.gov/ncidod/dhqp/gl_isolation.html http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html (Intravascular catheter-associated Staphylococcus aureus septicemia only) 27,737 cases/$84,976 Clostridium difficile-associated disease (CDAD) http://www.cdc.gov/ncidod/dhqp/gl_isolation.html http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#9 Source: Centers for Medicare & Medicaid Services 96,336 cases/$59,153 MAY 2008 / MANAGED CARE 35 http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html http://www.cdc.gov/ncidod/dhqp/gl_isolation.html http://www.cdc.gov/ncidod/dbmd/diseaseinfo/ http://www.legionella.org/ http://www.diabetes.org/uedocuments/InpatientDMGlycemicControlPositionStmt02.01.06.REV.pdf http://www.diabetes.org/uedocuments/InpatientDMGlycemicControlPositionStmt02.01.06.REV.pdf http://www.ncbi.nlm.nih.gov/pubmed/1485006 http://www.ahrq.gov/clinic/ptsafety/chap28.htm http://www.rcjournal.com/cpgs/09.03.0869.html http://www.chestjournal.org/cgi/reprint/126/3_suppl/172S http://orthoinfo.aaos.org/topic.cfm?topic=A00219 http://www.cdc.gov/ncidod/dhqp/gl_isolation.html http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html http://www.cdc.gov/ncidod/dhqp/gl_isolation.html http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#9
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