27 May 2008

Hospital gives patient MRSA. Should Medicare reimburse?

You have until June 13th to tell the government what you think. Details of how to comment at the end of this post because they are complicated.

Here's the back-story: Until recently, hospitals were reimbursed by the Center for Medicare and Medicaid Services (part of the US Department of Health and Human Services) whenever they provided care to Medicare or Medicaid patients, even if that care included a mistake, error or hospital-acquired infection. Thankfully, that is beginning to change. Last December, CMS proposed a rule change. In the agency's language:
Beginning October 1, 2008, Medicare will no longer pay hospitals at a higher rate for the increased costs of care that result when a patient is harmed by one of several conditions they didn’t have when they were first admitted to the hospital and that have been determined to be reasonably preventable by following generally accepted guidelines. (Quoted from this press release.)
In other words: Hospitals, you break it, you bought it.

These are the conditions for which, as of Oct. 1, 2008 (the first day of federal fiscal year 2009), Medicare will not reimburse:
  • Object inadvertently left in after surgery
  • Air embolism
  • Blood incompatibility
  • Catheter associated urinary tract infection
  • Pressure ulcer (decubitus ulcer)
  • Vascular catheter associated infection
  • Surgical site infection - Mediastinitis (infection in the chest) after coronary artery bypass graft surgery
  • Certain types of falls and trauma.
Note: MRSA is not on that list. But: At the same time, CMS proposed a second set of error-related conditions for which it will consider not-reimbursing, based on public comment. Some of those conditions are MRSA-related. The conditions are:
  • Surgical site infections following certain elective procedures.
  • Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)
  • Extreme blood sugar derangement
  • Iatrogenic pneumothorax (collapse of the lung)
  • Delirium
  • Ventilator-associated pneumonia
  • Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)
  • Staphylococcus aureus septicemia (bloodstream infection)
  • Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)
CMS will decide whether or not to include any or all of those additional events by Aug. 1. The non-reimbursement would start at a later date that the first list.

This a complex topic and there is a long paper trail attached to it. Fact sheets are here. Definitions of the conditions, as accepted by CMS and the CDC, are here. The records of the Dec. 17. 2007 hearing in which this was discussed, including complete transcripts, is here.

Directions for how to comment electronically and by mail and hand-delivery (faxes are not accepted) are contained in this long Federal Register entry. Here is how to do it electronically:
  • Go to http://www.regulations.gov
  • Under "Comment or Submission," enter this file-code: CMS–1390–P
  • Click on "Send a comment or submission" in the left-middle of the page.
  • Fill out the form that comes up (you may have to page-down to see the full form).


Anonymous said...

Medicare cutbacks in reimburesements may worsen the situation-this remains to be seen. I'd like to see real management deal with surgical groups who consistently have the highest wound infection rates-we nurses know who they are and direct our loved ones and ourselves elsewhere. Poor nutrition, lack of understanding/use of probiotics during use of antibiotics and failure to provide proper discharge teaching of homecare with a MRDO add to the problem.

What about Super Klebsiella, E. Coli, VRE and Pseudomonas? All of these bugs are fallout from the mis-use of antibiotics by both medical practioner AND patient.

How will we know if the patient or visitor brought the bug in with them-do surveillance cultures on everyone?

It's sad that the threat of monetary punishment is needed to drive home basic infection control procedures. But how about better pay, more reasonable work expectations for the cleaning people within our institutions? They should be at the core of infection control as well as transporters, and other ancillary staff. How often are stretchers cleaned between patients-never.

If only the people who do the work were asked to contribute to the thought processes needed to eliminate infections. Poor health care consumers-they are at the bottom of the medical 'food chain', not at the top where they belong.

Anonymous said...

Not only "mis-use" but also "intended use" by intensive farming of cattle and other animals wherein antibiotics are administered to increase weight gain and to treat infections caused by crowding conditions. Antibiotics and their metabolites are then released into the water table.

See also silver embedded (titanium oxide) in socks released into the waste water.

Only laws against such practices will protect us from the unintentional evolution of resistant pathogenic microbes.

Maryn McKenna said...

Silver socks?? How did I miss this?