updating Medicare payments to
hospitals for fiscal year 2009, the Centers for Medicare and Medicaid
Services (CMS) added three new conditions to the list of
hospital-acquired conditions (HAC) for which Medicare will not pay at
the enhanced complication/comorbidity payment level.
Because two of the three conditions relate directly to orthopaedic
procedures, many AAOS fellows have expressed considerable concern
about their impact. This article attempts to address those concerns.
Two issues should be clarified immediately. First, Medicare will
continue to pay for the primary procedure or service. Second, this
hospital inpatient policy does not affect physician payments; it only
affects payments to the acute inpatient hospital setting.
The following three conditions were added in the final rule:
-
surgical site
infection (SSI) following certain elective procedures (including
orthopaedic procedures)
-
deep vein
thrombosis/pulmonary embolism (DVT/PE) in total knee replacement (TKR)
and total hip replacement (THR)
-
manifestations of
poor glycemic control
Differences from the original proposal
Although CMS originally proposed SSI in TKR as a potential HAC, the
final rule does not include TKR among the elective orthopaedic
procedures under the SSI HAC. Additionally, the DVT/PE HAC is limited to
TKR and THR patients only.
The
total impact of the DVT/PE HAC is that for primary (not revision) hip
and knee patients who do not have other significant comorbidities and
who sustain a PE (not a DVT) during their initial hospitalization,
hospitals will not be eligible to receive an incremental reimbursement
based on the existence of PE alone. This is much different from
statements that CMS will not pay for DVT/PE after elective orthopaedic
procedures because development of a DVT does not actually have payment
implications for TKR and THR. Therefore, this policy affects an
extremely small number of patients.
Finally,
CMS reduced the original 43 proposed measures for the hospital quality
data reporting program to 13 finalized measures. Because the hospital
inpatient setting is on a fiscal year cycle, the policy goes into effect
on Oct. 1, 2008.
AAOS
efforts
The American Association of Orthopaedic Surgeons (AAOS) met with CMS
several times and submitted comments on SSI in TKR and DVT/PE as HACs.
On June 13, 2008, AAOS submitted a comment to CMS on the HAC payment
policy.
AAOS
proposed changes to the musculoskeletal Medicare severity
diagnosis-related groups (MS-DRGs) but CMS did not accept any of them.
The AAOS
shares the CMS goal of promoting high-quality, safe, and effective care,
but is concerned that including complications that are not always
reasonably preventable to the HAC list may have unintended consequences
that could negatively affect patient access and quality of care. The
AAOS will respond with a strong comment and meeting to discuss the
potential threats on patient access to orthopaedic care.
Jacque
Roche is a federal policy analyst and Lindsay Law is communications
manager in the AAOS office of government relations.
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