Survey Report: Medicare Out of Line in Refusing to Pay for Mistakes

Six out of every 10 respondents to a MedPage Today poll said Medicare's decision not to reimburse hospitals for the extra costs of treating preventable injuries is overly punitive.

Beginning a year from October, officials at the Centers for Medicare and Medicaid Services say, Medicare will stop paying for the cost of treating patient falls, pressure ulcers, urinary tract infections, vascular-catheter-associated infections, mediastinitis, air emboli, removal of objects left in the body during surgery, and injury caused by use of incompatible blood products. (See: Medicare Buck Stops at Paying for Hospital Mistakes)

The proposed rule change also prohibits hospitals from billing patients for "any charges associated with the hospital-acquired complication."

The implications of that decision could be far-reaching, so we asked visitors to MedPage Today whether the Medicare rule is overly punitive for often financially strapped hospitals.

Only 40% of the 854 respondents felt the rule would provide a strong incentive to beef up quality standards.

One respondent summarized the feelings of that minority, noting that a hospital "should accept responsibility for its actions (or, inactions) like any other business."

Many of those who came down on the side of the majority, however, took exception to whether Medicare's list included truly preventable injuries.

One respondent, who has spent years doing quality-assurance work, said, "I came to realize that patients were often accidents waiting to happen, set up for UTIs and other problems before they even hit the door."

Even those who didn't take the patient's condition on admission into consideration found problems with the definition of "preventable problems." Some noted that accidents happen in all walks of life.

One noted many instances of unavoidable situations, including the "patient's right to fall." Said she, "the rules against restraint use, coupled with staffing issues and the family's inability or unwillingness to sit with patients, also play into that one! Is the hospital responsible for that as well?"

Hospital staffing levels were raised by a number of respondents. Said one, "While I accept the likelihood that accidents can and do occur even when the level of care is high, I'd be willing to bet that the preponderance of accidents occur because the level of patient care and attention to detail by hospital staff is lacking in many cases."

Said a nurse, "if staffing was better and we were allowed to do more nursing and less paperwork, patients would get far superior treatment and the statistics for complications would go way down."

A bigger nursing staff would, of course, come at a price. One respondent recognized that: "This is a set-up for an inevitable increase in health care costs as providers and hospitals institute non-evidence-based practices such as increased antibiotic prophylaxis, and unnecessary preoperative/pre-admission diagnostic testing/imaging in an attempt to identify pre-existing conditions. In the end, Medicare will pay out more, not less."

"Having Medicare decide what is preventable is a recipe for disaster," said one doctor. "About the only thing it will accomplish is to increase the number of physicians and hospitals that opt out of the Medicare system, thereby limiting patient access to health care and, in essence, making them sicker when they do become hospitalized. Ultimately, the rule defeats its own whole purpose."

At least one respondent, however, had a solution that could satisfy both sides. Recognizing that complications can occur naturally in spite of a hospital's best efforts, he says, "I think the best solution would be for Medicare to pay a fixed percentage of the costs associated with a condition based on estimates of how often it could reasonably be prevented."

"So," he continued, "if it's estimated that 20% of UTIs could be prevented, Medicare would pay 80% of the normal costs associated with UTIs when they're contracted in hospitals."