Medicare's no-pay conditions: Not always preventable

AMA delegates voice strong objections to a new rule that would deny hospitals payment for certain conditions patients develop in the facility.

Editorial. July 14, 2008.

Some ideas, no matter how well-intentioned, have negative consequences that quickly become apparent. This is the case with Medicare's new policy on hospital-acquired conditions.

Beginning on Oct. 1, the program no longer will pay hospitals for the added cost of treating up to 17 conditions when patients develop them in the facility. The medical problems on the list -- eight are finalized and nine have been proposed for inclusion -- are deemed by the government to be reasonably preventable by following generally accepted guidelines.

The government's goal is to improve care and save Medicare millions of dollars. Sounds great, right?

But problems exist at the initiative's most basic levels -- the assumptions that the presence or absence of these conditions at admission can always be determined and that all of them reasonably can be avoided. The effort's failings are addressed in a new policy passed by the American Medical Association House of Delegates and in a June AMA comment letter to the Centers for Medicare & Medicaid Services.

Some of the medical problems on the no-pay list -- such as Legionnaires' disease -- can lie dormant and aren't discernible when the patient arrives. Hospital pay would be unfairly reduced in these cases.

In some situations -- emergency care, for example -- testing at admission isn't feasible. Even in nonemergency cases, screening could cause delays that could harm patient care.

The idea that all the conditions on the no-pay list are reasonably preventable doesn't hold up to scrutiny either, as AMA Executive Vice President and CEO Michael D. Maves, MD, MBA, points out in the comment letter. Delirium provides a striking example. First, it has many causes, such as dementia or psychiatric disorders, that can be minimized but not necessarily prevented by following appropriate quality measures. Second, sometimes the proper standard of care can cause the condition. For example, Dr. Maves notes, high-dose steroid treatment for patients with brain metastases or cord compression can cause elevated blood sugars and delirium.