The descriptions to be used in coding are very detailed. UTIs, for example, have one code to document the POA assessment, another code to show that a UTI occurred, and a third code to indicate it was catheter-associated. Each code requires appropriate documentation in the chart (see Table 1, above).
The impact hospitalists have on care and payment is not the same across the HAC spectrum. For instance, documenting the presence of pressure ulcers might be easier than distinguishing colonization from infection in those admitted with in-dwelling urinary catheters. Others, such as DVT or vascular catheter-associated infections, are rarely POA unless they are part of the admitting diagnosis.
“This new focus on hospital-acquired conditions may work to the patient’s benefit,” Dr. Meddings says. “The inclusion of pressure ulcers has led to increased attention to skin exams on admission and preventive measures during hospitalizations. In the past, skin exams upon admission may have been given a lower priority, but that has changed.”
Dr. Meddings is concerned that the new rules could force the shifting of resources to areas where the hospital could lose money. If, when, and how many changes will actually take place is still up in the air. “Resource shifting is a concern whenever there is any sort of pay-for-performance attention directed toward one particular complication,” she says. “To balance this, many of the strategies hospitals used to prevent complications are not specific to just the diagnosis that is covered by the HAC.”
Dr. Meddings also hopes the new focus on preventable conditions will have a “halo effect” in the healthcare community. For instance, CMS mandating DVT prevention following orthopedic operations will, hopefully, result in a greater awareness of the problem in other susceptible patients.
POA Indicators
Dr. Meddings
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Since hospitalists often perform the initial patient history, physical, and other admission work, they are in the best position to find and document POA indicators (see Table 2, p. below). Proper notes on such things as UTIs present and the state of skin integrity are an important part of making sure the hospital is paid correctly for the care it provides.
Education on the specific definition of each potential HAC is required to help physicians avoid overtreatment of certain conditions, especially UTIs. For example, the Centers for Disease Control and Prevention (CDC) defines all UTIs as symptomatic. Therefore, the screening of all admitted patients, regardless of symptoms, is wasteful and unlikely to help the hospital’s bottom line.
“If you start screening everyone that comes through the door so you don’t miss any pre-existing UTIs, you are going to find a lot of asymptomatic colonization,” Dr. Wald says. “You are also going to spend a lot of money and time on studies and possibly treatments that may not yield many true infections. It is important that physicians know the definition of these HACs to help avoid needless interventions.”
Minimal Loss
Many hospital administrators and physicians were worried when the HAC program was first announced. Much of the stress and concern, however, seems to have dissipated. CMS estimated the HAC program would save Medicare $21 million in fiscal year 2009. Others, such as Peter McNair and colleagues writing in Health Affairs, suggest the actual impact is closer to $1.1 million.1 The CMS-projected impact of the HAC provision in fiscal-year 2009 was $21 million, out of more than $100 billion in payments.
“I think the HACs will not have a major impact because of the way payments are made,” says internist Robert Berenson, MD, a fellow at the Urban Institute in Washington, D.C., who has studied Medicare policy issues extensively, and for two years was in charge of Medicare payment policies at the Health Care Finance Administration, the precursor to CMS. “Patients who have HACs often have another comorbidity that would kick them into a higher payment category regardless of the presence of a hospital-acquired complication. In the end, it is probably more symbolic and unlikely to make a major dent in hospital income—at least at this point.”