Final 2016 Medicare inpatient rule contains provisions to promote patient safety

September 28, 2015

On July 31, 2015, the Centers for Medicare and Medicaid Services (CMS) released the FY 2016 Inpatient Prospective Payment System (IPPS) Final Rule. This Final Rule contains the policies and payment rates that will be effective for hospitals starting Oct. 1, 2015.

Ultrasound Guidance to Reduce Adverse Events
Several studies demonstrated that the use of ultrasound to guide a thoracentesis can reduce the adverse event of an iatrogenic pneumothorax, and that the use of ultrasound to a paracentesis can reduce the adverse event of an arterial puncture. In both cases there are evidence-based guidelines to follow for practices to stop such adverse events from happening. And their number, and costs to the Medicare program, are not insignificant. Therefore, the imaging community, in its efforts to promote patient safety through the use of appropriate imaging, has been talking with CMS about adding these two conditions to the Hospital Acquired Conditions program.

This would mean that if a patient has one of these events happen during a hospital stay, the hospital would not receive a higher payer MS-DRG based solely on that complication. In the 2016 IPPS Final Rule, CMS reported that it had RTI, its contractor, begin researching available evidence-based guidelines for the two conditions. A positive development in the process, RTI released a report that summarizes the two conditions titled “Evidence-based Guidelines Pertaining to Select Thoracentesis- and Paracentesis-Related Conditions,” which is available at index.html?redirect=/hospitalacqcond/06_ hospital-acquired_conditions.asp.

Due to time constraints and the demands of the system moving to ICD-10-CM on Oct. 1, 2015, CMS could not fully evaluate each of these two recommended conditions against all established criteria, nor review the references submitted by the imaging community in their comments and meetings with CMS, or perform detailed analysis of the ICD-10 codes in time for discussion in the FY 2016 IPPS/LTCH PPS final rule. However, CMS is taking these comments under consideration as it develops proposed changes to the HAC program for FY 2017. Hospitals may want to consider advancing evidence-based clinical practice guidelines in this area.

Catheter-Based Blood Stream Infections
Another patient safety area that has long been a focus of CMS and many of the quality reporting programs is catheter-based blood stream infections. The objective has been to bring their numbers down to zero. In this final IPPS rule, CMS went ahead with its proposal to expand the counting on a number of CLASBI’s that a hospital has. This includes all departments within a hospital, rather than specific areas like critical care, which had been the prior method. This will impact a hospital’s scores for the hospital-acquired conditions reduction program and the valued-based payment program.

CMS also finalized that the percentage of risk for hospitals in the valued-based payment program will go to 1.75 percent of total Medicare allowables. Moreover, the hospital acquired conditions reduction program will again be counting hospitals’ acquired conditions in FY 2016 with the bottom quartile. This is to say that the hospitals with the highest numbers will have their Medicare allowables reduced by 1 percent in FY 2017, based on FY 2016 numbers.

To learn more about the FY 2016 Final IPPS Rule, please visit the CMS webpage at FY2016-IPPS-Final-Rule-Home-Page.html

About the author: Jill Rathbun is managing partner at Galileo Consulting Group in Arlington, Virginia. She will be commenting for HealthCare Business News on issues of interest to health care professionals.