Medicare Reforms Reduce Hospital-Acquired Conditions

Lara C. Pullen, PhD

December 16, 2014

The 2008 Centers for Medicare & Medicaid Services (CMS) payment reform includes a refusal to pay for treatment of certain preventable hospital-acquired conditions. This refusal has translated into a lower incidence of hospital-acquired pulmonary embolism (PE) or deep vein thrombosis (DVT) after knee and hip replacement surgery.

Risha Gidwani, DrPH, and Jay Battacharya, MD, PhD, from Stanford University in California, published the results of their difference-in-differences modeling online December 12 in the Journal of General Internal Medicine. They designed their model to evaluate whether fee-for-value reimbursement strategies are able to effectively drive the medical system toward higher-quality care at lower total costs. Theirs is the first study to analyze the effect of the new CMS payment policy on the incidence of PE and DVT.

The researchers obtained data (2007 - 2009) from the Nationwide Inpatient Sample, a nationally representative database of community hospital discharges. They considered discharges of patients admitted for knee and hip replacement surgery that occurred between January 1, 2007, and September 30, 2008, to be "before payment reform." The retrospective analysis of administrative data relied on International Classification of Diseases, Ninth Revision, Clinical Modification, billing codes.

The investigators analyzed four groups of patients: 65- to 69-year-old Medicare recipients, 60- to 64-year-old non-Medicare recipients (control), 65- to 69-year-old non-Medicare recipients (control), and 65- to 69-year-old privately insured patients (control).

They based their model on hierarchical linear regression and used each hospital as a random effect to account for the cluster of observations within the hospital. The investigators also included a length-of-stay covariate in the model to control for the possibility that Medicare patients had been discharged earlier, before they had the opportunity to develop PE or DVT.

At baseline, PE and DVT occurred in 0.81% of all hip or knee replacement surgeries performed on Medicare patients aged 65 to 69 years. The CMS policy change was independently associated with a 35% reduction in the incidence of hospital-acquired PE and DVT in this patient group. The incidence of PE and DVT simultaneously increased in the non-Medicare patient groups.

The difference in the incidence of PE and DVT between the Medicare and non-Medicare population became obvious in early 2009, approximately 3 months after the implementation of the CMS policy.

The researchers acknowledge that the percentage point reduction appears small, but they point out that it represents a major cost savings for the Medicare program, given the volume of hip and knee surgeries in the United States.

The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online December 12, 2014.

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