MEDICARE TAKES NEW STEPS TO HELP MAKE YOUR HOSPITAL STAY SAFER
When you enter the hospital for treatment of one medical problem, you don’t expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, too often patients suffer from injuries or illnesses that could have been prevented if the hospital had taken proper precautions.
As part of its commitment to improve the quality of care you receive during a hospital stay, and to make sure that Medicare only pays for items and services that are reasonable and necessary, Medicare is taking new steps to make hospitals safer by adopting payment policies that will encourage hospitals to 1) reduce the likelihood of hospital-acquired conditions like certain infections, advanced bed sores, or fractures; and 2) reduce preventable medical errors, like performing surgery on the wrong body part, that should never happen.
What they are:Medicare has selected conditions that are reasonably preventable by following evidence-based guidelines and that are either costly or common. These conditions include:
- Foreign object (such as a sponge or needle) inadvertently left in patients after surgery
- Air embolism - an air bubble that enters the blood stream and can obstruct the flow of blood to the brain and vital organs
- Transfusion with the wrong type of blood
- Severe pressure ulcers – deterioration of the skin, due to the patient staying in one position too long, that has progressed to the point that tissue under the skin is affected (Stage III), or that has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints (Stage IV)
- Falls and trauma:
- Joint dislocation
- Head injury
- Crushing injury
- Electric shock
- Catheter-associated urinary tract infection (UTI)
- Vascular catheter-associated infection
- Manifestations of poor control of blood sugar levels
- Surgical site infection following coronary artery bypass graft (CABG)
- Surgical site infection following certain orthopedic procedures
- Surgical site infection following bariatric surgery for obesity
- Deep vein thrombosis (a blood clot in a major vein) and pulmonary embolism (blockage in the lungs) following certain orthopedic procedures
What Medicare is doing: Since October 1, 2007, hospitals have been required to report on their Medicare claims if any of the first eight selected conditions were present at the time the patient was admitted to the hospital, and beginning October 1, 2008, will have to report on the remaining conditions as well. If at discharge, there is a selected condition that was either not identified by the hospital as present on admission, or could not be identified based on data and clinical judgment at admission, it is considered hospital-acquired. To encourage hospitals to avoid hospital-acquired conditions, beginning October 1, 2008, Medicare will no longer pay hospitals at a higher rate for the increased costs of care that result when a patient is harmed by one of the listed conditions if it was hospital-acquired. Medicare prohibits the hospital from billing the beneficiary for the difference between the lower and higher payment rates.
Medicare will pay for physician and other covered items or services that are needed to treat the hospital-acquired condition, including the costs of post-acute care that would not have been needed for the patient’s initial medical problem, but are needed because of the hospital-acquired condition.
Medical Errors That Should Never Happen (“Never Events”)
What they are: There are some events that should never happen in a hospital. When they do occur, they can cause serious injury or death to the patient. The National Quality Forum (NQF) has defined these as Serious Reportable Adverse Events, commonly referred to as “never events.” These events are also likely to be very costly both for the beneficiary and the Medicare program. Some examples of “never events” include:
- Surgery on a wrong body part
- Surgery on a wrong patient
- Wrong surgery on a patient
What Medicare is doing: In most cases, Medicare pays only for items or services that are reasonable and necessary for the treatment of the patient’s condition, or certain preventive services required by the Medicare law. For the three wrong surgeries listed as examples above, Medicare is opening a National Coverage Decision process to look at how to ensure that patients get necessary care, but that the Medicare program would not pay the doctor and the hospital for an erroneous surgery.
WHAT DOES THIS MEAN FOR ME?
The most important impact for you, and those who care for you when you are ill or incapacitated, is that you should receive higher quality care during your hospital stay. With these Medicare payment rules, hospitals have additional incentives to make more thorough assessments of your condition at admission, to have systems in place to prevent adverse events from occurring during your stay, and to prevent you from undergoing surgery that you do not need and that may result in permanent injury. To the extent that these policies succeed in reducing the frequency of hospital-acquired conditions and wrong site surgeries, you, as both a patient and a taxpayer, should pay less, while getting better outcomes.
HOW CAN I FIND OUT MORE ABOUT QUALITY?
The quality of the care you get in the hospital is important to your health. Hospitals should follow accepted standards of practice to prevent hospital acquired-conditions and Never Events. If you have concerns about the quality of care you received while in the hospital, call the Quality Improvement Organization in your state. Call 1-800-MEDICARE (1-800-633-4227) to get the telephone number. TTY users should call 1-877-486-2048.
For information about the quality of care provided by hospitals in your area, see the “Hospital Compare” feature on our Web site at www.medicare.gov.
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