Medicare's no-pay conditions: Not always preventable

Some ideas, no matter how well-intentioned, have negative consequences that quickly become apparent. This is the case with Medicare's new policy on hospital-acquired conditions.

Beginning on Oct. 1, the program no longer will pay hospitals for the added cost of treating up to 17 conditions when patients develop them in the facility. The medical problems on the list -- eight are finalized and nine have been proposed for inclusion -- are deemed by the government to be reasonably preventable by following generally accepted guidelines.

The government's goal is to improve care and save Medicare millions of dollars. Sounds great, right?

But problems exist at the initiative's most basic levels -- the assumptions that the presence or absence of these conditions at admission can always be determined and that all of them reasonably can be avoided. The effort's failings are addressed in a new policy passed by the American Medical Association House of Delegates and in a June AMA comment letter to the Centers for Medicare & Medicaid Services.

Some of the medical problems on the no-pay list -- such as Legionnaires' disease -- can lie dormant and aren't discernible when the patient arrives. Hospital pay would be unfairly reduced in these cases.

In some situations -- emergency care, for example -- testing at admission isn't feasible. Even in nonemergency cases, screening could cause delays that could harm patient care.

The idea that all the conditions on the no-pay list are reasonably preventable doesn't hold up to scrutiny either, as AMA Executive Vice President and CEO Michael D. Maves, MD, MBA, points out in the comment letter. Delirium provides a striking example. First, it has many causes, such as dementia or psychiatric disorders, that can be minimized but not necessarily prevented by following appropriate quality measures. Second, sometimes the proper standard of care can cause the condition. For example, Dr. Maves notes, high-dose steroid treatment for patients with brain metastases or cord compression can cause elevated blood sugars and delirium.

CMS calls the conditions on the list "never events," a misnomer that a delegate to the June AMA Annual Meeting described as creating an unrealistic standard of perfection. The new Medicare policy could add to doctors' liability risks by fostering the false notion that the no-pay conditions should never occur.

Many of these medical problems are more difficult to avoid in high-risk patients, for example those with multiple comorbidities or those at the end of life. The new rule encourages hospitals to avoid these patients because of the financial threat they pose. The AMA letter, among other recommendations, urges CMS to drop high-risk patient populations from the payment policy for most of the proposed conditions.

The no-pay rule requires conditions to be documented upon admission, but it is unclear who would be doing the documenting. Physicians? Hospital personnel? Regardless, the outcome will be increased administrative hassles and costs.

Discovering if patients have the conditions requires testing -- lots of it. Screening all patients would raise costs for Medicare and patients.

All these flaws combined result in an initiative whose costs will outweigh the financial and patient care benefits.

The program needs some serious revisions. At the meeting, AMA delegates passed several policies on the subject, including one instructing the Association to continue its strong opposition to nonpayment for conditions that are not reasonably preventable through use of evidence-based guidelines. The AMA comment letter names eight such conditions and urges the agency to remove them from the list.

Delegates expressed concern that CMS might expand the no-pay policy to the physician practice setting. As Dr. Maves states in his letter, "it would defy any logical rationale to extend an approach to other settings when it is not clear that the approach achieves its quality-improvement goals and, in fact, may cost significantly more money."

While the CMS policy is well-meant, its current structure carries with it too many unintended consequences for patients and Medicare.