CMS seeks to add 9 hospital-acquired conditions to no-pay list

The Centers for Medicare & Medicaid Services last month proposed to stop paying for nine hospital-associated conditions that it says can be prevented and that cost Medicare about $25 billion last year.

The nine conditions would join a list of eight others adopted last year. CMS will stop paying for those eight this October. While some welcomed the proposal as a sign Medicare is stepping up efforts to encourage hospitals to improve patient safety, others said CMS should wait to see how implementation of the first round of no-pay conditions unfolds.

Under the proposal, hospitals still would be paid for hospitalizations but would not be allowed to code and charge for the following as "complicating conditions" if they develop during a patient's stay:

• Surgical-site infections after total knee replacement, laparoscopic gastric bypass and gastroenterostomy, or ligation and stripping of varicose veins.
• Legionnaires' disease.
• Diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma or hypoglycemic coma.
• Iatrogenic pneumothorax.
• Delirium.
• Ventilator-associated pneumonia.
• Deep-vein thrombosis or pulmonary embolism.
• Staphylococcus aureus septicemia.
• Clostridium difficile-associated disease.

Some hailed the Medicare proposal.

The new no-pay list "makes very logical sense as an extension of ongoing work by Medicare to more closely link outcomes with appropriate payment and to emphasize solid, evidence-based practices that may not be well-adhered to," said David B. Nash, MD, PhD, editor of the American Journal of Medical Quality. "Every one of these [conditions] has solid, grade-A evidence behind it that makes it incontrovertible that we ought to be preventing it."

But others disagreed. Nancy Foster, the American Hospital Assn.'s vice president for quality and patient safety policy, said conditions such as delirium and C. diff. disease lacked strong evidence of preventability.

"We would love to reduce all complications in care," Foster said. "There has to be good evidence that someone has been able to employ a strategy that has driven incidence to near zero. ... Otherwise, it's just a wish."

Robert Wachter, MD, said Medicare should wait to see how the first round of no-pay conditions plays out and what if any unintended consequences arise. This is especially so, he said, because hospitals are still mastering a new set of codes that will allow them to charge for conditions that are present on admission.

Dr. Wachter, chief of the medical service at the University of California, San Francisco, Medical Center, said no-pay conditions should be preventable, measurable, harmful and detectable on admission. None of the newly proposed conditions meet all those criteria. "CMS is at risk of running way beyond the evidence here," he said.

The American Medical Association objected to the first no-pay list, arguing that the policy could discourage hospitals from caring for the sickest patients who are most vulnerable to hospital-acquired conditions. The Association also said it is unclear whether the newly proposed conditions are reasonably preventable.

"The AMA is concerned with the new list of conditions proposed for hospital nonpayment, and we will be sharing these concerns with CMS through their formal comment process," said AMA Board of Trustees Chair Edward L. Langston, MD. "The AMA will also be working with the medical state and specialty societies to examine the clinical appropriateness of the proposed conditions."

Comments will be accepted through June 13, and CMS will issue a final rule by Aug. 1.