Managed Care - May 2008 - (Page 36) and procedural codes — is dwarfed by a much bigger change. For discharges occurring on or after Oct. 1, Medicare will no longer pay the additional costs incurred by hospitals when certain hospital-acquired infections develop or when certain medical errors occur. Specifically, hospitals “will not receive additional payment for cases in which one of the selected conditions was not present at admission,” according to the new CMS rules. “That is, the case would be paid as though the secondary diagnosis [were] not present.” Health plans are following Medicare. In addition to Aetna, WellPoint, the largest plan by enrollment, is doing the same thing in Virginia with four errors from the NQF never-events list, including leaving a sponge or other object in a patient after a procedure or performing the wrong procedure. The company says it will extend the policy to its plans in New England, New York, and Georgia. UnitedHealth Group and Cigna said they will be following suit sometime this year. The Blue Cross Blue Shield Association publicly says that all 39 members are looking at similar measures. The amount of money saved by the plans may be minimal, however. In Minnesota, where hospitals are required by law to report such errors, only 154 NQF never events were reported last year out of 9 million hospital admissions, according to recent reports. a few never events — are expected to save the federal government $20 million in fiscal year 2009, according to a CMS statement, and health plans may well expand their contract stipulations to include the kind of hospital-acquired infections CMS will no longer pay for. “It’s not going to be just CMS,” Craig Becker, president of the Tennessee Hospital Association, said recently. “It’s going to be everybody.” Public comment will be accepted through June 13 on the additional nine conditions that CMS no longer wants to pay for. The final rule will be issued on or before Aug. 1. Challenge to health plans The big savings will come if health plans stop paying for all hospital-acquired conditions, not just never events. The Centers for Disease Control & Prevention estimates that patients develop 1.7 million infections in hospitals a year, causing or contributing to as many as 99,000 deaths a year. On average, urinary-tract infections and hospital-acquired pneumonia can add more than $10,000 to a patient’s hospital bill. A serious antibiotic-resistant bloodstream infection can result in more than $100,000 in extra costs. Such common problems total more than $4.5 billion in additional health spending a year, according to the CDC. MS-DRGs — with the emphasis on hospitalacquired and preventable infections in addition to Quality reporting measures There is one more significant change happening under the new rules associated with MS-DRG: Hospitals now report 27 quality-related measures to CMS in order to receive the full annual update to Medicare’s payment rates. CMS also announced on April 14 that it proposes to add 43 new quality measures to the 30 measures now listed in its voluntary reporting of standardized quality measures. These are measures that are publicly reported on Hospital Compare, the CMS public Web site for comparing hospital quality reports (http://www.hospitalcompare.hhs.gov/). The agency must receive data about these measures for a hospital to receive its full inflation update for fiscal year 2010. The additional measures, if adopted in the final rule following a public comment period, will take effect Oct. 1, 2008, for fiscal year 2009. The move to severity-based payments and especially the refusal of CMS to pay for treatments for conditions not present on admission is a sign that the times are indeed changing. “Tying payment to the quality of care represents the future of health care,” says Premier’s Pane. “It was inevitable.” MC More information about MS-DRG is available at the CMS Web site. Fact sheets for all the proposed changes, and the current final changes, are at http://www.cms.hhs. gov/apps/media/fact_sheets.asp. The 1,047-page description of MS-DRG in the Federal Register, which includes information on review process, may be found at a257.g.akamaitech.net/7/257/2422/01jan20071800/edo cket.access.gpo.gov/2007/pdf/07-3820.pdf or http://tinyurl.com/2m3pps . 36 MANAGED CARE / MAY 2008 http://www.hospitalcompare.hhs.gov/ http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gpo.gov/2007/pdf/07-3820.pdf http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gpo.gov/2007/pdf/07-3820.pdf http://tinyurl.com/2m3pps
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