Question 1:
As of 1 October 2008, hospitals would not receive extra payment for cases where pressure ulcers were not present on admission. The deficit reduction act (DRA) was signed on 8 February 2008. Section 5001(c) of DRA requires the secretary to identify conditions that are:
(a) High cost or high volume or both (Becker, 2010).
(b) Result in the assignment of the case to a DRG that has a higher payment when present as a secondary diagnosis (Becker, 2010).
(c) Could reasonably have been prevented by following evidence-based guidelines (Becker, 2010).
The CMS has the right to revise the list of such conditions as long as they fulfill at least two conditions. Pressure ulcers or bedsores as they are also known fall under this group of conditions. The CMS does not reimburse any facility for pressure ulcers as a secondary diagnosis. This policy makes sense. The DRA aims to reduce the deficit experienced in the health sector. It works by reducing the money paid out to hospitals for conditions that is highly avoidable.
Pressure ulcers cost a lot to treat and many patients in long-term stays at the facilities experience them. This means that they form a significant part of the total money spent on healthcare. What makes it appear on the list is that it is easily preventable. There are laid out guidelines which if followed would lead to reduction in their occurrence. Naturally, there were ethical issues raised by this policy.
When the CMS stopped reimbursing hospitals for such diagnosis, the patients were forced to pay for their treatment. This was unfair to the patients since the ulcers were no fault of their own. The workload at the facility may also be too much for the health care workers to follow all the guidelines correctly. Instead of refusing all cases, the policy should refuse to pay when it is established that the ulcers occurred because of negligence on the part of the health care workers.
Question 2:
The hospital can avoid the adverse conditions affecting payment. This will be carried out by altering the systems for receiving referral patients and for taking care of admitted patients. The administrator should ensure that the guidelines regarding care for patients are enforced. When these guidelines are enforced, the instances where pressure ulcers affect patients in the hospital’s care would be minimized. When these instances are reduced, the hospital would reduce the money lost to non-reimbursed funds.
Any patient who is being admitted into the hospital should be thoroughly examined to ensure that all conditions are identified. The administrator should ensure that the nursing facility presents a clear medical history of the patient on referral. The receiving doctor should then crosscheck the patient with the report given. This will ensure that cases where a patient is admitted with a secondary condition are minimized.
In case of such conditions existing on a patient, the skilled nursing facility would be required to indicate their existence. This would ensure that the hospital would be reimbursed for any costs associated with treating such a patient. The administrator can also provide some of his staff to help train the workers at the skilled nursing facility. This would ensure that they are able to handle all the patients in their care correctly. This would reduce the chances of such conditions affecting the patients while at the facility.
References
Becker, J. M. (2010). A guide to coding compliance. Clifton Park, NY: Delmar Cengage Learning.
Youngberg, B. J. (2011). Principles of risk management and patient safety. Sudbury, Mass: Jones and Bartlett Publishers.
