New Medicare Rules Mean Better Hospital Care

Medicare is changing their rules again. Starting in October, Medicare will no longer pay for hospital acquired illness, challenging hospitalists to rev up admission screening methods and remain vigilant about errors. Frequent visits to patients to check for new developments, such as bedsores and infection from invasive tubes and IV’s are on the agenda of daily "to do’s" for nurses, doctors and hospital team members.

The Medicare In-patient Prospective Payment System (IPPS) rules added eight conditions that fall under the category of non-payment Examples include falls that result in injury, and surgical instruments left inside patients. Does this mean that if your doctor makes a boo – boo, you’re going to pay? It unlikely that will happen. For years, hospitals have been getting the money when things go wrong. Hospitals will now have the increased burden of making sure that mishaps don’t occur, and that’s great news for healthcare consumers.

One way hospitals plan to tackle the changes is by educating physicians to perform better documentation on admission, and make more frequent bedside visits. Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM's Hospital Quality and Patient Safety Committee says, “What we will be doing is looking at ways to include this primarily into our electronic documentation. Templates are being offered in one hospital with reminders to ask specific questions, known as “Present on Admission Indicators (POAI’s). Others are attempting to “cue” physicians with electronic charting options that will lead to nurses and doctors toward automatic thinking rather than answering “yes or no” when assessing patient conditions. Dr. Harte says multiple opportunities for good documentation may be a better approach than the “yes, no” template design.

Additional plans include the use of multi-specialty physicians on general medical floors, not just specialty units. More tests might be ordered on hospital admission, but decisions about what kind of tests will be left up to the doctor's good judgment. Designated teams will inspect and advise about wound care and IV maintenance to prevent infection.

Medicare changes usually pose problems. Hospital diagnoses can be coded in the following ways: “can be coded as present on admission”,” not present on admission”, “unable to determine because the documentation was lacking”, or “unable to clinically say”. Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine provides the following example of a patient who is admitted through the emergency room with chest pain and later develops a urinary tract infection. She points out the difficulty as follows - “Did the ED doc screen for a UTI on admission? Probably not. It would be 'clinically unable to determine,' from the way I'm reading it, because they didn't have testing on admission. So in this case, it would behoove you not to screen." Dr. Wald co-wrote the commentary, "Nonpayment for Harms Resulting from Medical Care" in the December 2007 Journal of the American Medical Association (JAMA).

Nevertheless, there is a goal that dictates better patient care, while increasing the work of hospitalists. Urinary tract infections (UTI’s), blood infections, and ulcers will now become a part of physicians' daily assessment. More focus will be put on the need for invasive IV lines and urinary catheters, a big source of hospital infections. Documentation will become challenging and time consuming.

The changes in Medicare reimbursement are significant when you consider that hospitals make more money when patients get sicker, a fact that is soon to be past tense. Major insurance companies are sure to follow Medicare’s lead. Now you won’t have to wonder what’s going on when your doctor really gives you a good head to toe exam after you gown-up, something many patients are sure to notice. You won’t be able to hide that minor skin condition you've ignored, and yes, the Dermatologist just might be in to see you.