Message to Medicare: Test before finalizing rules

When the policymakers and rule writers toiling away at the Centers for Medicare and Medicaid Services dream up their next regulations that tighten the link between pay and performance, I can only hope that they will consider testing the rules before forcing hospitals to follow them.

Apparently, good intentions aren't enough to achieve policy goals. Here's a case in point:

The hospital-acquired condition payment rule says that for discharges from Oct. 1, 2008, on, hospitals will not get extra payments for cases in which any of 10 specific conditions was not present on admission.

This no-payment rule was designed to help Medicare save money and motivate hospitals to develop systems to prevent conditions such as hospital-acquired catheter-associated urinary tract infections, pressure ulcers, and falls.

It's a noble enough goal, although I must note that some have argued that not all of the conditions on the list are preventable. Another problem lies with the execution.

CMS depends on billing records to determine whether one of these conditions was "present on admission" vs. hospital-acquired. Yet a June 2010 article in Infection Control and Hospital Epidemiology revealed how the administrative records often do not jive with what's in medical records, so payments may be based on incorrect bills.

In fact, when comparing what coders wrote and what was in 80 randomly chosen records for patients discharged with secondary-diagnosis UTIs, University of Michigan researchers found significant differences.

Hospital coders listed 25 percent of UTIs as hospital-acquired, while the physician-abstractors said 46 percent were. The coders found no CAUTIs, while physician-abstractors found that 45 percent of the discharges involved CAUTIs. Plus, the researchers noted that catheter use was evident only from nursing notes, which unlike physician notes, cannot be used by coders to assign discharge codes, the researchers wrote.

They concluded that hospital coders rarely use the catheter association code that should have been used to identify CAUTIs among the secondary-diagnosis UTIs. Coders also often listed UTIs as present on admission, letting the hospital off the hook, although the medical record indicated that it was hospital-acquired.

While this study was conducted based on records from May 2006 through Sept. 2007--long before the no-payment rule took effect--the results suggest that because coding of hospital-acquired CAUTIs seems fraught with error, one can't be sure that CMS' policy would be executed correctly.

Incorrect coding means that the nonpayment, as mandated by the hospital-acquired condition initiative, would not be triggered. The hospital would be paid by default, and the policy's financial incentive to improve care would dissolve.

What's more, to effectively implement the policy, an industrial strength auditing process would have to be put in place, and it could erode any financial gains that were anticipated via nonpayment for certain complications.

It's not enough to collect public comments for two months. Maybe next time, CMS should run a pilot test before assuming that a plan will work as envisioned. - Sandra