Should Hospitalists Who Fail to Provide a Standard of Care Be Paid for Subsequent Care?

Clearly, withholding payment in this scenario is an ineffective mechanism for improving quality or decreasing cost. I am not generally a proponent of rewarding failure, and perhaps as we usher in a new era of healthcare reform, the system will be redesigned in such a way that better aligns quality and cost-control measures. However, under the current system, payment denial as outlined above likely does more harm than good.

CON

Withhold payment when medical errors are easily identifiable

Dr. Axon is a hospitalist and assistant professor in the departments of Internal Medicine and Pediatrics at the Medical University of South Carolina in Charleston. He is a member of Team Hospitalist.

When I first learned of the proposal to withhold Medicare payment for hospital-acquired conditions (HACs), I had mixed emotions. On the one hand, I firmly believe that physicians should be accountable for their work; on the other hand, this policy seems to conflict sharply with the “no blame” mantra that has been prevalent in patient safety for more than a decade.2 More recently, though, many have argued for balancing the pursuit of system fixes for quality and patient-safety issues with the development of a culture of accountability.3

In theory, the HACs should meet the following criteria: They should be high-cost conditions, high-volume conditions, or both; they should be identifiable through ICD-9-CM coding as complicating conditions (CCs) or major complicating conditions (MCCs) that result in a higher-paying MS-DRG; and they should be reasonably preventable through the application of evidence-based guidelines. Some HACs are jaw-dropping lapses in care (e.g., leaving foreign bodies in during surgery). Other HACs seem to me to be much less preventable, especially fall injuries and catheter-associated urinary tract infections (UTIs). Several experts have written eloquently regarding the limitations of these new measures, particularly emphasizing the potential for increased administrative burden on hospitals and the potential for unintended consequences.4,5

However, in the case described above involving a hospitalist, I have no reservations in limiting payment to the provider. To me, failing to prescribe VTE prophylaxis in an elderly, immobilized, post-op hip replacement patient with a CHF exacerbation is the hospitalist’s equivalent to a surgeon leaving behind a sponge in an appendectomy. It also meets the elements outlined in the HAC withholding program:

• It is high-cost. The 2007 MS-DRG payment for elective hip arthroplasty was $9,863, but adding an MCC increased that cost by one-third.6
• It is readily identifiable, though one concern might be that hospitals would perform unnecessary pre-operative testing to identify asymptomatic DVT, incurring increased testing and treatment costs and increasing the incidence of bleeding complications.
• It is very preventable. Without thromboprophylaxis, 40% to 60% of hip arthroplasty patients will develop an asymptomatic DVT, and 1 in 300 will die from a PE. However, such fatal events are exceedingly rare with appropriate prevention.7

Ultimately, I think a policy of nonpayment for this case keeps with the culture of accountability we need to foster in healthcare. The financial implications of nonpayment will drive hospital innovation and force the hospital to police provider behavior in more effective ways. This is likely to be a painful process, similar to the tribulations experienced with implementing pay-for-performance programs. The Centers for Medicare and Medicaid Services (CMS) needs to be flexible in adding—and removing—new HACs based on good evidence.

Regardless, the goal of achieving a safer, more effective healthcare system remains.

References

1. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857.
2. Institute of Medicine. To Err Is Human: Building a Safer Healthcare System. Washington, D.C.: National Academies Press; 2000.
3. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361:1401-1406.
4. Saint S, Meddings JA, Calfee D, Kowalski CP, Krein SL. Catheter-associated urinary tract infection and the Medicare rule changes. Ann Intern Med. 2009;150(12):877-884.
5. Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-2393.
6. Wachter RM, Foster NE, Dudley RA. Medicare’s decision to withhold payment for hospital errors: the devil is in the det. Jt Comm J Qual Patient Saf. 2008;34(2):116-123.
7. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):381S-453S.