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 Medicare in the US, which provides coverage for the elderly and disabled, says it will no longer pay for treating patients who are injured in the care of a hospital or other care facility. Serious pressure ulcers are among the ten “reasonably preventable” conditions on its initial list.  download a PDF version
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Medicare “no-pay” rule effective October
From October 2008, Medicare and Medicaid Service announced it will no longer reimburse hospitals for treating preventable pressure ulcers (Stages III and IV). Source: American Medical News August 2008 / Wall Street Journal September 5, 2007 Hospitals around the country are scrambling to put new programs in place to prevent pressure ulcers after the federal Centers for Medicare and Medicaid Services announced last month that as of October 2008, it will no longer reimburse hospitals for treating eight "reasonably preventable" conditions. Pressure ulcers are among the most prevalent, costly and dangerous on the list. In addition to interfering with recovery, lengthening hospital stays, and causing extreme pain and discomfort, pressure ulcers can increase the risk of infection, with nearly 60,000 deaths annually from hospital-acquired pressure ulcers. Nursing homes and long term care facilities have made strides of their own in prevention, motivated in part by the costs of litigation for failure to prevent pressure ulcers. But in acute-care hospitals, where patients stay for much shorter periods, prevention has been sporadic. Acute-care hospitals treat about 2.5 million pressure ulcers each year, and as many as 15% of hospitalized patients may have pressure ulcers at any one time, according to the Institute for Healthcare Improvement. Estimates for the cost of treating all pressure ulcers in the U.S. range up to $11 billion annually. To combat this, hospitals are pushing screenings of all incoming patients from head to toe for skin issues that could lead to pressure ulcers. They are using visual examinations, ultrasound and other technologies that can help identify skin with tissue damage. In some cases, they are photographing areas of a patient's skin to document how it changes from day to day. Hospitals are also buying special beds with high-tech air mattresses that minimize or redistribute pressure. And they are adhering to strict monitoring schedules that include shifting patients every two hours, frequently cleaning and moisturizing soiled or sensitive skin, and making sure that at-risk patients have enough protein and other nutrients in their diet to help the healing process. |
Patients often arrive at the hospital with pre-existing skin lesions, and researchers say some ulcers may simply be unavoidable in patients with severe disabilities or compromised immune systems. Generally, however, experts agree that pressure ulcers are a classic example of preventable harm. Despite strong evidence of effective strategies for prevention, guidelines are frequently ignored or overlooked. Part of the problem is a nationwide nursing shortage that makes for a more harried and chaotic hospital environment. But there has also been no real incentive for prevention programs, since Medicare and private insurers typically pay for complications that arise once a patient is in the hospital. That is changing with the advent of Medicare's new payment policy, which some private insurers are considering following. In addition to pressure ulcers, the preventable conditions for which Medicare will no longer reimburse hospitals include injuries from patient falls, urinary-tract infections, vascular-catheter-associated infections and mediastinitis, an infection following heart surgery. Also included are so-called ‘never events’, meaning they never should happen – objects left in the body during surgery, air embolisms and blood incompatibility. Medicare plans to add three additional conditions next year. Last year, there were 322,946 cases of pressure ulcers as a "secondary diagnosis" (in addition to the primary reason the patient entered the hospital) reported in Medicare patients. The cost of treating a severe pressure ulcer with complications that require surgery can be as high as $70,000, studies show. Critics of Medicare's new rules say unreimbursed costs for pressure-ulcer treatment will simply be passed along in higher medical charges for everyone. But Medicare counters that the new policy will give hospitals a strong incentive to screen patients who may be at risk. If hospitals can document that the skin ulcer was present at admission, it will pay for treatment. The no-pay list Medicare finalized a list of types of conditions for which, starting October 1, it will no longer reimburse hospitals at the higher diagnosis-related group rate.
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