CMS reducing pay for HAC.

According to the Centers for Medicare and Medicaid Services (CMS), there is significant public backing for reduction in Medicare payments for hospital-acquired conditions (e.g., methicillin-resistant Staphylococcus aureus or MRSA, and blood or transplant incompatibility). The Deficit Reduction Act of 2005 is part of CMS' value-based purchasing strategy, requiring Medicare to revise diagnosis-related group (DRG) payments for specifically defined HAC. The FY2008 Acute Inpatient Prospective Payment System (IPPS) Final Rule required most hospitals to begin reporting this information to CMS on Oct. 1, 2007, through the Present on Admission (POA) indicator, defined by CMS as "present at the time the order for inpatient admission occurs or conditions that develop during an outpatient encounter, including the emergency department, observation, or outpatient surgery."

The HHS Secretary had to identify at least two HAC by last October, based on high cost or high volume, or both; whether they resulted in a secondary diagnosis with higher DRG payment than if primary diagnosis; and whether they could reasonably have been prevented through the application of evidence-based guidelines. The FY2008 IPPS Final Rule delineated three HAC categories that, when present, trigger a higher payment as either a complicating or major complicating condition: those 1) selected for implementation in FY2008; 2) considered for FY2009; and 3) needing further analysis. The following HAC are being implemented for FY2008; the four bolded HAC can and will be directly affected by the lab. "Serious Preventable Events" include an object left in during surgery; air embolism; blood incompatibility; and "Other HAC" include catheter-associated urinary-tract infection; vascular catheter-associated infection; surgical-site infection--mediastinitis after CABG surgery; and falls and trauma--fractures, dislocations, intracranial injuries, crushing injuries, and burns.

In addition, last Oct. 1, CMS required POA indicators be reported for all primary and secondary inpatient diagnoses at affected hospitals. On Jan. 1, 2008, Medicare provided comments and returned (but did not reject) incorrectly submitted POA information. On April 1, 2008, Medicare began rejecting incorrect POA submissions and will no longer pay additional monies for selected diagnoses not present on admission on Oct. 1.

The Joint Commission (TJC) Goal 1, in the 2008 National Patient Safety Goals (NPSG), is to improve the accuracy of patient identification. In the draft version of the 2009 NPSG, Requirement 1C provides an additional level of safety related to patient identification for transfusion. The expectation for implementing 1C, eliminate transfusion errors related to patient misidentification, states: Either two people are to verify the patient before transfusion, or some form of automated identification device be used, such as a handheld barcode reader at the beside." Regardless of the method for identifying the patient, human accountability for transfusion or transplant requires top-down support.

The other three bolded previous HAC are hospital-acquired infections (HAI) and are also included in the draft of the 2009 NPSG, under Goal 7, reduce the risk of healthcare-associated infections. TJC participated in developing the guidelines for HAIs, which are to be published shortly in The Society for Healthcare Epidemiology of America's journal. Infection Control and Hospital Epidemiology. [As of this writing, the planned electronic publication in March had not yet occurred.]

The expectations found in the subsets of Goal 7, are based on publications from the Healthcare Infection Control Practices Advisory Committee--a federal advisory committee made up of 14 external infection control experts. Requirement 7C is an overview of guidelines to decrease and prevent infections by multidrug resistant organisms (MDRO). Catheter-associated urinary-tract infections may be caused by MDRO as well as other organisms. Two mentioned in 7C, MRSA and Clostridium difficile-associated disease, are listed as possible HAC to be rejected by Medicare for payment in the next two years. Requirement 7D delineates best practices for preventing catheter-associated blood-stream infections (CABSI), and 7E, surgical-site infections (SSI). The laboratory has a direct influence on four of the seven FY2008 HAC listed above and is given a prominent role in implementing these best practices. Expectations for 7C-7E, requiring significant laboratory input are:

* education of healthcare staff about MDRO, CABSI, and SSI, and the absolute need to work on prevention;

* measurement of infection rates, monitoring compliance, and evaluation of outcomes-of-prevention effort;

* presenting data collected to appropriate hospital staff and physicians;

* performing risk assessments;

* implementation of a surveillance plan to identify and track patients positive for these specific organisms; and

* provision of an alert system to identify newly infected patients and one for readmission of formerly infected patients.

Financial incentives are part of the Medicare HAC/POA reporting and reductions in reimbursement for conditions acquired while in a facility can decrease the hospital's bottom line. The fiscal viability of hospitals with a high percentage of Medicare patients will be especially affected by these changes.

Approximately 60% to 80% of the diagnostic information used by physicians to diagnose inpatients comes from the laboratory. Implementation of HAC and POA, and Goal 7 Expectations in the current draft of TJC 2009 NPSG will likely place a significant responsibility on the lab to provide the needed information in a timely manner. Regular review of the following websites will be of assistance in providing updates on federal and accreditation regulations: www.jointcommission. com, www.cms.hhs.gov, www.cap.org, www.cdc.gov, and www.iom.edu.

Pam Tayon Colker, MT(ASCP), MBA, is director of Laboratory Services at Palms of Pasadena Hospital, St. Petersburg, FL. She has 25 years' experience in hospital and commercial laboratory settings, with 11 years as a laboratory consultant.

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By Pam Tayon Colker MT(ASCP), MBA