Medi Care Rule Change by Peter Menkin

By DerrikKyle on July 1, 2010, 7:28 pm

Medi Care payment rules changed in October, 2008. They will no longer pay the extra costs of treating patients who develop eight serious, preventable conditions after hospitalization. The list includes falls from bed, cathers-associated urinary tract infections and pressure ulcers. News reports indicate large insurance companies are considering similar policies. “Never Events”, hospital attributable medical errors, make up part of the list of the rule changes.

The Center for Medi Care and Medicaid (CMS) notes, “On February 8, 2006 the President signed the Deficit Reduction Act (DRA) of 2005 that required there be an adjustment in Medicare DRG (Diagnosis Related Group) payment for certain hospital-acquired conditions.”

Asking key questions of Health and Human Services regarding the rule changes:

(1) Who pays, and how/why if Medi Care no longer will pay?

The hospital absorbs the cost of treating the hospital-acquired condition, and may not bill the beneficiary for the difference between the two Medicare Severity Diagnosis Related Groups (MS-DRGs).

(2) Is there a limit on their payment, should the infection prove long and difficult in severity and length? Is there the likelihood of long severity of non-covered infection?

In unusual cases in which the costs of treatment greatly exceed the payment rate for the case based on the assigned MS-DRG, Medi Care may pay the hospital an outlier payment. In these cases, after the hospital’s costs of treatment exceed the MS-DRG payment rate by an outlier threshold, Medicare will begin to pay 80 percent of any additional costs. .. [T]he final rule included a tentative outlier threshold for fiscal year 2009 of  $20,185.   CMS plans to announce the final outlier threshold, after taking into account the MIPPA changes, soon.

(3) Why this change in the rule (budget issue?)?

These changes were mandated by the Deficit Reduction Act of 2005.

(4) Why have they picked these diseases?

These are not all diseases.  They are properly called “hospital-acquired conditions,” because they also include things like falls. .. [T]he public was given 60-days to comment, and were selected based on a review of the submitted comments.  According to criteria established in the Deficit Reduction Act of 2005, each condition had to be:

(5) What do they expect to be the result of the new policy? An opinion is desired

.

CMS Acting Administrator Kerry Weems says:

“While it may be some time before we can begin to assess the real impact of these steps on patient care, we are hearing from hospitals around the country about efforts they have undertaken in the past year to improve staff training and other measures to reduce the incidence of these preventable conditions.”

Many experts believe that these important changes will drive payment methods and criteria in the near future, and that the adjustments will motivate hospitals to reduce “Never Events.”

–Peter Menkin, San Francisco

 

 

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