Medicare Says Hospitals Must Pay for Mistakes

By Debbie Gilbert

Talk about adding insult to injury.

Sometimes patients leave the hospital with problems they didn’t have when they first came in. They fall and break a hip, or they get an infection after surgery.

In the worst-case scenario, a hospital employee makes a mistake that causes a patient’s death.

Now Medicare is telling hospitals, if you mess up, you pay up.

As of Oct. 1, the federal agency will no longer reimburse hospitals for eight preventable conditions that occur after the patient is admitted.

"The hospital absorbs the cost of treating the hospital-acquired condition and may not bill the beneficiary for the difference," said Ellen Griffith, spokeswoman for the Centers for Medicare & Medicaid Services.

She said the new rule is part of a legislative mandate in the Deficit Reduction Act of 2005. It’s intended to give hospitals a financial incentive to follow accepted standards of care.

In 1999, the Institute of Medicine estimated that medical errors may cause as many as 98,000 deaths a year. In response to that study, health agencies began looking at ways to reduce the number of "never events," things that should never happen if a hospital is observing the right protocols.

These include operating on the wrong body part, leaving a foreign object inside the patient after surgery and transfusing the wrong blood type.

Medicare has also singled out conditions that are common in hospitals but could be prevented with proper precautions, including patients being injured by falling, urinary tract infections caused by catheters and severe bedsores.

Next year, Medicare plans to expand the list, adding pneumonia in patients who are on ventilators, septic blood infections and blood clots that travel to the lungs.

Hospitals, anticipating the upcoming rule change, are already taking steps to prevent mistakes and to deal with them when they happen.

Last week, the Georgia Hospital Association announced a new statewide billing guideline, encouraging hospitals not to charge patients or private insurers for "serious preventable events."

"Most have not charged in the past," said association spokesman Kevin Bloye. "But we wanted to formalize this policy. It creates an environment of transparency."

Association vice president Vi Naylor said the association began considering such a policy long before the Medicare rule was written.

"We started a program, the Partnership for Health and Accountability, seven years ago," she said.

Though it is possible that patients who are not charged for a hospital’s mistake may be less likely to file a malpractice lawsuit, Bloye said the move has nothing to do with avoiding litigation.

"It’s just an assurance to the patient that, ‘Hey, we’re going to take care of this,’" he said.

Taylor said the association has not calculated how much it will cost hospitals to absorb the unreimbursed charges.

At Northeast Georgia Medical Center in Gainesville, spokeswoman Cathy Bowers said it has been a standard practice for years not to bill the patient for something that the hospital did wrong.

But Lynda Adams, director of performance improvement at the medical center, said it’s inevitable that some of the "events" on Medicare’s list are going to occur.

"It’s easy to say these things shouldn’t happen in the hospital, but they do, and it’s not necessarily always the hospital’s fault," she said.

For example, several items on the list are related to hospital-acquired infections. Employees are supposed to follow strict rules, such as frequently washing their hands, to prevent transmission of germs. But Adams said patients who are already in poor health when they enter the hospital are much more susceptible to developing infections.

Nevertheless, hospitals continue to strive to do the best they can. Adams said the medical center has a patient safety committee as well as subcommittees on specific issues, such as preventing falls and controlling infections.

She said the hospital staff never assumes that only elderly patients get injured in falls.

"Upon admission, every patient is evaluated for their risk of falls," she said. "Even young patients are at risk if they’re on certain medications."

Those deemed at risk are more carefully monitored, Adams said, and sometimes changes are made in the patient’s room to reduce the likelihood of a fall.

Often a small measure of prevention can make a big difference, she said. For example, to help prevent pneumonia when a patient is on a ventilator, the head of the bed is always kept raised.

"Now our ventilator-associated infection rate is almost nonexistent," Adams said.

To prevent urinary tract infections, she said, "We try to remove the (urinary) catheter as soon after surgery as possible. In the old days, patients often remained on a catheter during their entire hospital stay, just because it was convenient."

Adams said preventing pressure sores is one of the toughest challenges for nurses, even when patients are turned frequently and kept on specially cushioned mattresses.

"If a patient’s nutritional status is poor, their skin breaks down easily despite your efforts," she said.

But with bedsores being added to Medicare’s nonreimbursement list, hospitals are expected to focus more aggressively on prevention.

As for the "never events," Adams said no hospital wants the embarrassment of a major mistake such as amputating the wrong limb. So there are numerous safeguards already in place.

"We mark the body part for surgery, with the patient aware and involved in the process," she said. "There’s an extensive list of checks that have to be done before the first incision is made."

As for making sure that a patient gets transfused with the right blood type, Adams said, "we have people in our blood bank whose only job is to ensure blood compatibility."

The medical center is still working on preventing one of the most common errors: giving a patient the wrong drug or the wrong dosage.

"We have a computerized system now for medication administration," Adams said. "That’s not to say we never have errors. We do. But look-alike drugs or ones with sound-alike names are kept in separate places. And both the drug and the patient (via wristband) are bar-coded."

Bowers said besides the financial burden of having to pay for mistakes, hospitals are also at risk for losing their accreditation if they don’t follow safety precautions.

"Any unexpected, serious outcome is called a ‘sentinel event,’" she said. "It must be reported, and it could lead to an investigation."