CMS Future HAC Plans? HAI Cost Impact on Hospitals?

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CMS Future HAC Plans? HAI Cost Impact on
Hospitals?

• Rick Sites
• General Counsel Senior Health Policy Director
• October 1, 2008

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Section 1996(d)(4)(D) of the Deficit Reduction
Act of 2005

• DRA required Medicare to identify HACs that are
  
• High cost, high volume or both
• Assigned to a higher paying DRG when present as
  a secondary diagnosis
• Could reasonably have been prevented through
  application of evidence based guidelines

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Lower Reimbursement for IPPS Hospitals Only

• Beginning October 1, 2008, Medicare will pay a
  case with an HAC as though the HAC did not occur
  (i.e., a lower DRG amount)
• Critical access, long-term acute care, rehab,
  psychiatric, cancer, and childrens hospitals are
  exempt at this time

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DRA Criteria for HACs

• Medicare data must support the selected
  conditions are high cost and/or high volume
• Selected conditions must have a diagnosis that
  identifies the condition and results in higher
  payment as a secondary diagnosis
• Selected HACs must be reasonably preventable
  through application of evidence-based guidelines

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Key HAC QuestionsCMS Must Answer

• Is there high cost, high volume per HAC?
• Does ICD-9 code clearly identify the HAC?
• Are there evidence-based guidelines?
• Is the HAC reasonably preventable?

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10 Selected HACs
Selected HAC Medicare Data (2007)
Foreign Object post op 750 cases _at_ 68,631 per hospital stay
Air Embolism 57 cases _at_ 71,636/stay
Blood Incompatibility 24 cases _at_ 50,455/stay
Pressure Ulcer Stages III IV 257,412 cases _at_ 43,180/stay
Falls and Trauma 193,566 cases _at_ 33,894/stay
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10 Selected HACs-Continued
Catheter-Associated UTI 12,185 cases _at_ 44,043
Vascular Catheter-associated Infection 29,536 _at_ 103,027/stay
Surgical Site Infection after CABG, Bariatric Surgery, Orthopedic Procedures 375 cases _at_ 184,398/stay
Poor Glycemic Control 14,929 cases _at_ 41,495/ stay
Deep Vein Thrombosis/Pulmonary Embolism 4,250 cases _at_ 58,625/stay
73 FR 48434 at pp. 48473, 48490 average from
combining DRGs
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Rejected HACs
Rejected HAC Medicare Date (2007)
Ventilator-Associated Pneumonia 30,867 cases _at_ 135,795/stay
Staphylococcus Aureus Septicemia 27,737 cases _at_ 84,976/stay
Clostridium Difficile-associated Disease 96,336 cases _at_ 59,153/stay
Legionnaires Disease 351 cases _at_ 86,014/stay
Iatrogenic Pneumothorax 22,665 cases _at_ 75,089/stay
MRSA 88,374 cases _at_ 32,049/stay
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CMS Estimated Medicare Savings From 10 HACs
Federal Fiscal Year Medicare Savings
2009 21 million
2010 21 million
2011 21 million
2012 22 million
2013 22 million
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Additional Potential Candidate HACs
Surgical site infection following device procedures
Failure to rescue
Death or disability associated with drugs, devices, biologicals
Events on the NQFs list of Serious Reportable Adverse Events
Dehydration
Malnutrition
Water-borne pathogens
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What Does the Future Hold for More HACs?

• There are 258 sets of DRGs with subgroups based
  on complication or comorbidity

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What Does the Future Hold?

• CMSs reduced payment for HACs has just begun
• Submit comments to www.regulations.gov
• Medicaid and private insurers are or will follow
  the CMS lead
• As to CMS and Medicaid, participating in the
  rulemaking process especially by submitting
  meaningful comments is critical