Since DRA 2005, Medicare has been busy identifying hospital errors that it won’t pay for. ACA gave HHS regulatory authority to expand this to Medicaid. On May 27, 2011, HHS published the final rule (h/t to Don’s On the Record). I read it last night (122 pages) so you don’t have to:
- New terminology (a key US health policy export):
| Old | New |
| Never events | National coverage determination (NCD) (surgery on the wrong patient, wrong surgery on a patient, and surgery on the wrong site) |
| Hospital-acquired condition (HAC) | Hospital-acquired condition (HAC) (existing Medicare inpatient rules, as updated from time to time) |
| Provider-preventable condition (PPC) (HCACs+ OPPCs) | |
| Health care-acquired condition (HCAC) (Medicare HACs, slightly modified for Medicaid; inpatient only) | |
| Other provider-preventable condition (OPPC) (all Medicaid provider settings (not just inpatient); NCDs + optional settings and conditions, defined by states in their Medicaid plans after process with CMS) |
- New conditions: 27 states currently require reporting of hospital-acquired infections or conditions. Under the final rule, states can refuse to pay for the modifiers for OPPCs after an evidence-based process with CMS, with the new conditions & payment rules defined in the Medicaid state plan. Instead of preempting state efforts, the new rules establish a floor for state experimentation, akin to HIPAA preemption.
- New settings: OPPCs (including NCDs) are not limited to inpatient hospital settings. Another impetus towards ACO integration.
- CMS intends to evaluate OPPCs for future inclusion as HACs.
- Rule effective July 1, 2011, but compliance enforcement delayed to July 1, 2012.
- CMS discussed in the preamble (at 30, 32) that not all “hospital-acquired” conditions were actually preventable, but leaned heavily on evidence-based guidelines and overall incentives to improve quality. In short: CMS knows that they will deny payment unfairly in some particular cases, but wants to send a “bundled” quality message to all providers. I wish they’d go further on germ sheds.
- Providers will invest $$ in “present on admission” (POA) diagnostics, as that is the best way to prove that an infection wasn’t a PPC.
Bottom line: a thoughtful rule, with a clear path for state experimentation.
