Medicare’s "no pay”" policy: An analysis of the Philadelphia area
Hospitals are on notice that they must step up their quality-improvement efforts in anticipation of Medicare’s “no pay” policy for specific hospital-acquired conditions, which was detailed in the Final Rule. In addition, reports indicate that many Medicaid and commercial insurance plans are expected to follow Medicare’s lead. For example, Pennsylvania’s Medicaid program plans to quickly adopt similar rules and may expand them to other preventable conditions, according to the article, “A financial ouch for hospitals,” published in the Aug. 31, 2007 issue of the Philadelphia Inquirer. The article reported that the conditions within Medicare’s “no pay” policies appeared in bills for an estimated 35,156 hospitalizations last year, according to the analysis of records for general hospitals in the eight counties surrounding Philadelphia. Currently, however, the records do not note whether the condition existed before the patients entered the hospital or if they developed during the hospital stay. Also, the article itemized the number of times (for the hospitals within the eight-county region) that these conditions appeared in Medicare bills during 2006:
| Philadelphia-Region Analysis | | Cases reported in Philadelphia’s eight-county region in 2006 that will not be covered by Medicare starting Oct. 1, 2008 | | Conditions that will not be covered | Number of cases | | Catheter-associated urinary-tract infections | 362 | | Objects left in body during surgery | 46 | | Air embolism (obstructive air bubble) | 1 | | Incompatible blood type | 9 | | Vascular catheter-associated infections* | 2,033 | | Mediastinitis (infection after heart bypass) | 11 | | Bedsores | 10,890 | | Hospital-associated injuries (breaks, burns, etc.) | 21,804 | |
| | * 2006 data includes more than catheters | | ** Excludes patients transferred from nursing homes, who often develop bedsores | | SOURCES: Analysis by Inquirer staff writer Josh Goldstein of data from New Jersey Department of Health and Senior Services (Burlington, Camden and Gloucester Counties) and Pennsylvania Health Care Cost Containment Council (Bucks, Chester, Delaware, Montgomery and Philadelphia Counties) | | Table published in Aug. 31 Philadelphia Inquirer | The full article can be read by clicking here.
Posted: 9/2/2007
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