Now Hospitals Must Pay for Avoidable Complications

Years in the making, a new Medicare rule that takes effect at midnight tonight should make hospital care a little safer. Here's how: If the cost of treating a Medicare patient is pushed up because one of a defined set of avoidable problems happened on the hospital's watch—such as a fall, bedsore, or urinary tract infection that occurred or arose after the patient was admitted—the Centers for Medicare and Medicaid Services will no longer reimburse the hospital for the additional expense. The incident will be considered a hospital-acquired condition, not a complication that up to now would have triggered a higher payment. (I described all this in detail in August of last year, when the rule was issued.)

Not only does this make sense—why should public funds be spent to prop up substandard hospital care?—but a very tangible financial incentive now exists for hospitals to do everything they can to avoid these events, which can bulk up expenses by tens or even hundreds of thousands of dollars. Some of the conditions on the CMS list are relatively rare, like the 24 instances last year of mismatched blood transfusions, but others are all too frequent, such as the 257,412 cases of advanced bedsores and 12,185 urinary tract infections in catheterized patients. (A major cause of these UTIs is that catheters are left in place too long, and one reason for this is that they are buried under the covers, so nurses and doctors can forget that they are there.)

CMS is urging states to apply the same new standards to Medicaid payments, which the states administer. About 20 have done so already.

Whether CMS will make individual hospitals' numbers and types of hospital-acquired conditions available to the public has not yet been determined, says an agency spokesperson.

What about nursing homes? If hospitals are improving safety and quality, the same cannot be said of nursing homes. A new report from the Office of the Inspector General of the Department of Health and Human Services, CMS's parent agency, finds that more than 90 percent of nursing homes were cited for one or more deficiencies in inspection surveys in 2005, 2006, and 2007. The average number of deficiencies last year was seven, compared with 6.9 in 2006 and 6.4 in 2005. It is small comfort that most of the deficiencies were related to urinary incontinence and other issues that are quite serious to those who suffer from them but generally do not cause lasting harm. Not quite 17 percent of nursing homes in 2007 had failings that put residents in jeopardy or injured or killed them, for example, by dehydration or infection.

By the end of the year, CMS intends to introduce a five-star rating system on its Nursing Home Compare page and to start incorporating feedback on satisfaction from residents and families. The idea is to give someone looking for a nursing home a quick and visual summary of its quality, and it's a good enhancement—as long as the information already on the site remains available.