Patient Safety and Harms that Impact Reimbursement

All healthcare administrators, physicians, nurses, ancillary staff, quality professionals, and most importantly patients and families, believe in providing the highest quality and safest delivery of care. 

For decades healthcare organizations have sought safe and high quality services for their patients. With a focus on decreasing harms to patients, organizations monitored falls, medication errors, medication near misses, hospital acquired infections, length of stay, radiology accuracy, and mortality to name a few. This was the key concept prior to pay for performance (P4P or Value Based Purchasing). The fact was that we did just that – we monitored, we reported and we monitored and we reported. The cycle went on for years. There were negotiable improvements gleaned from this process.

In 2001 the second of two books, was published by the Institute of Medicine; Crossing the Quality Chasm (2001). It was a result largely in response to the first book To Err is Human: Building a Safer Health System (1999) which focused on Patient Safety. A key phenomenon discovered was that nationwide in all healthcare systems, by all providers, there was great variability in patients’ outcomes. There was great variability in the care and treatments of patients. 

It was here that the path was set to design “A New Healthcare System for the 21^st  Century” (To Err is Human 1998).

Over the next 10 years, organizations made some efforts to seek higher quality and patient safety improvements. Methodologies, based on evidence-based research, were put in place to not only identify the misses, the errors, the harms, and variances in outcome, but to add the research knowledge to the care and treatment guidelines.  

However there was a continued disappointment in how effective these initiatives were. Patients' outcomes still revealed a healthcare system that was harming patients and resultant low quality of care.

In 2002 the Joint Commission developed a set of evidence-based performance measures that hospitals reported. These clinical quality measures satisfied both regulatory (CMS) and accreditation requirements. 

The initial set of measures, often referred to as “Core Measures,” were:

• Acute Myocardial Infarction (AMI) - 8 measures
• Heart Failure (HF) – 4 measures
• Pneumonia (PN)  -7 measures
•  Surgical Infection Prevention (SIP or SCIP) – 2 measures

As an additional measure, patient satisfaction was brought into the set:

• HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) – 1 measure

In 2011 the Centers for Medicare and Medicaid Services (CMS) released the final rule on Hospital Value Based Purchasing. This document, of 195 pages, outlined the Processes of Care and HCAHPS measures that hospitals must meet to maintain full reimbursement from CMS. 

Additionally private insurance companies began following this lead. Initially HCAHPS made up 30% of the measure and Process of Care made up 70%. 

The percentages have evolved over time. For fiscal year 2016 these percentages which directly impact reimbursement will be as follows:

·         HCAHPS – 25%

·         Outcomes – 40%

·         Process of Care - 10%

·         Efficiency – 25%

As we evolved to a more robust Pay for Performance (P4P) program, the emphasis is on not only improvement of quality and patient safety, but on optimal reimbursement for care. An overwhelming stimulus for P4P becomes the rate of growth in health care costs. Total spending for healthcare was estimated as 16 percent of the GDP (Gross National Product) in 2007 and predicted to rise to 25 percent of GDP in 2015 (National Conference of State Legislators, Publication for Nonpayment for Medial Errors; August 2008).  

Based on sentinel events and other research, CMS chose patient conditions that negatively affected the patient’s outcomes. Organizations named these “Never Events.”  Because the Never Events were hospital acquired and did not relate to the patient’s original diagnosis, Medicare would not reimburse the hospital for their care and treatment. These conditions were originally selected based in the facts that:  

a)the condition is associate with a high cost of treatment, 

b) if billed as a secondary diagnosis; the organization would reap a greater reimbursement, and 

c) most importantly the condition could be reasonably  prevented if the organization followed evidence based research and practices.  

If organizations did not adopt Patient Safety initiatives to prevent these conditions, reimbursements would be negatively affected. The Never Event conditions are:

• ·         Object left in after surgery
• ·         Air embolism
• ·         Blood incompatibility
• ·         Hospital acquired catheter associated urinary tract infections
• ·         Hospital acquired decubitus ulcers
• ·         Hospital acquired vascular catheter infections
• ·         Surgical site infections
• ·         Falls with injury
• ·         Poor blood sugar control
• ·         Deep vein thrombosis

Because these conditions are preventable, lengthen length of stay, increase costs and overall reduce the patient’s outcome, hospital organizations are under pressure to reduce and eventually eliminate patient harms completely. 

Hospitals have adopted organizational wide forums or committees  to review, analyze and recommend improvements across all departments. 

With a focus on reducing avoidable harms or Never Events, Quality leaders and Patient Safety Officers are leading these efforts with the collaboration with physicians and administration.  Data from safety organizations such as the National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ) and Center for Disease Control (CDC) are used by CMS to develop goals for avoidable harm reduction.

Today patient safety improvement efforts continue to be a focus of reducing patient harm. The stakes continue to rise as in 2010 the Patient Protection and Affordable Care Act resulted in increased penalties in reimbursement for low quality performance and poor patient safety results.

 Hospital Engagement Networks (HEN) have been developed. These are grant-funded collaborative  initiatives designed to determine best practices for harm reduction and also to educate organizations on the practice of the best practices with a goal of reducing Hospital Acquired Conditions. The caveat for an organization to be a HEN, or be a part of one, is the resultant optimal reimbursement from Medicare. 

As quality leaders and patient advocates, we realize the best result of decreased patient harms is the improved health of the entire population. 

In 2015, 17 HEN’s were awarded grant funds to continue this work for harm reducing thus improving patient safety (2015 Partnership for Patients/CMS).

Contributed by Rebecca Janssen, Adjunct Faculty SJC