Big Momma Feds: Hospitals, clean up your act

Medicare is the Big Momma of health insurance, and when Big Momma talks, everyone listens. So when Big Momma smacks you upside the head, as Medicare did American hospitals last week, you better get to doing what Big Momma wants done. What she wants is for patients to be made safer in American hospitals. Don’t we all.

That Medicare wants fewer preventable errors and complications in the care of hospitalized patients is no surprise. The big surprise was Medicare’s announcement it will no longer pay hospitals for what it regards as errors and preventable complications in hospital care, including pressure ulcers (“bed sores”), infections from bladder catheters and central lines (big IVs in big veins), injuries from patient falls while hospitalized, extra surgery to remove sponges and other things left in during initial surgery, and transfusion of blood of the wrong blood type. That is a huge change in the way things have always worked, as though you threw the ball for your dog and Fido just looked up and said, “Get it yourself!”

And if Medicare is not going to pay for something then you can bet big insurers such as Anthem, Cigna, Aetna, and big employer groups such as the Leapfrog Group, are sure to follow suit (some have already taken this step). This will magnify the economic significance of Medicare’s decision.

A few hospitals have been ahead of this trend, already deciding on their own not to charge patients or health insurers for clear errors in hospital care. Most have done so as part of a new approach to errors that includes informing patients and families when errors have been made, telling them what the hospital has done to prevent a recurrence of the error, and apologizing for the error. However, none have gone as far as Medicare’s decision not to pay for what it regards as preventable complications in hospital care.

In its announcement, Medicare made little distinction between what are clearly hospital errors (transfusing blood of the wrong type or leaving in a sponge during surgery) and what are potentially preventable complications of appropriate care (such as infections from central lines). That’s because Medicare believes most of these complications can largely be prevented by fastidious compliance with techniques that minimize risk of the complication.

Given that central line infections result in the death of 40 percent of patients who get them and cost about $25,000 in extra hospital care, and that the Centers for Disease Control estimates about 100,000 Americans die in hospitals each year as the result of hospital-acquired infections, Medicare’s approach has widespread support outside the hospital industry, even if it includes a few Medicare errors.

The significance of Medicare’s announcement that it will not pay for these errors and complications goes way beyond the dollars that hospitals will lose. First, Medicare’s announcement is another signal it has gone from just being a payer for health care to being a health care purchasing gorilla willing to use its market clout on behalf of patient safety and other Medicare priorities.

Second, Medicare’s announcement means the financial burden of certain errors and potentially preventable complications will fall squarely on hospitals, thereby adding to the growing financial risk hospitals have in care that is not as complication-free as possible.

Third, Medicare’s approach may signal the end of the current version of the national pay for performance model – one of the hottest trends in healthcare – in which there was going to be extra money put into healthcare to help pay for improvements in care. Instead, Medicare seems to be saying hospitals will just get usual reimbursement from Medicare for high-quality care, and cuts in reimbursement for lower quality of care. This pay for performance version 2.0 will mean punishment for hospitals that do not improve, instead of additional financial incentives for those that do, and perhaps less cost for Medicare.

Across the country some hospital spokespersons have said Medicare’s decision may cause hospitals to do more tests to make sure patients don’t already have infections when they are admitted, that some of these complications on Medicare’s list (such as pressure ulcers) occur even when hospital care is perfect, that hospitals are already working hard to prevent these problems, that Medicare’s action will add costs to already expensive care, etc. While they are right, the answer to those hospital industry concerns will largely be silence, because the influence of the hospital industry in the hospital safety and quality debates is waning fast. That is why Congress – our representatives – told Medicare in the first place to develop a list of errors and potentially preventable complications for which it would not pay, and why Medicare’s action has been widely supported by consumer groups.

That silence points out the fourth and final significance of Medicare’s action; the American hospital industry appears to have surrendered its leadership of the issue of how to improve quality and safety of care in hospitals to a Big Momma federal government tired of waiting for American hospitals to clean up their room. Hospitals will pay for that error, too.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.