Residents' Awareness of and Response to Medicare's Rule on Nonpayment for Hospital‐Acquired Conditions: A Little Knowledge Can Be a Dangerous Thing

1University of California, San Francisco, San Francisco, CA
2University of California, San Francisco, San Francisco, CA
3University of California, San Francisco, San Francisco, CA
4University of California, San Francisco, San Francisco, CA
5University of California, San Francisco, San Francisco, CA

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 72

Background:

Medicare has selected 10 hospital‐acquired conditions for which it will not reimburse hospitals unless the condition is documented as being “present on admission.” This “no‐pay‐for‐errors” rule may have a profound effect on the clinical practice of physicians. The purpose of this study was to determine whether resident physicians are aware of this new rule and whether knowledge of the rule results in changes in practice.

Methods:

We performed a randomized trial of a brief educational intervention of residents in specialties that care for hospitalized patients at the University of California, San Francisco. We surveyed residents on their knowledge of the new rule and attitudes toward documentation requirements. To determine how their behavior may be affected by the rule, residents were randomized to receive either a 1 ‐page description of the rule (intervention group) or no information (control group). All residents were then asked to respond to 5 clinical vignettes in which no‐pay‐for‐errors conditions might be present on admission. For example, for “hospital‐acquired vascular catheter‐associated infection,” a vignette described a patient without evidence of infection who needed a central line. Three options were presented: 1 option represented appropriate care (place the central line), and 2 reflected unnecessary or inappropriate care (place the line but also send blood cultures or start antibiotics).

Results:

The survey was administered in December 2008. There have been 136 responses (39%) to date. Residents acknowledged responsibility to know Medicare documentation rules but most felt poorly trained to do so (mean response 1.64 ± 0.79 on a 5‐point Likert scale, from 1 = inadequate training to 5 = sufficient training). Most residents were aware of the rule (84% in the intervention group and 83% in the control group) but were unaware of the impact and specifics. For example, 85% of residents thought that under the new rule a hospital would receive no payment, rather than reduced payment, if a patient experienced a hospital‐acquired condition. Only 57% knew that “manifestations of poor control of blood sugar levels” was a no‐pay‐for‐errors condition, and only 58% knew that “pulmonary edema from excessive intravenous fluids” was not. In 4 of 5 vignettes, more residents in the intervention group selected options with inappropriate care. This was statistically significant for 2 of the vignettes.

Conclusions:

Most residents are aware of Medicare's no‐pay‐for‐errors rule but are unfamiliar with important details of the policy. Also, residents do not feel adequately trained in documentation. Providing information on the rule may result in residents performing additional tests or procedures that are not clinically indicated. Teaching residents about present‐on‐admission documentation is thus necessary (and desired by residents) but has the potential for unintended consequences.

Author Disclosure:

S. Mookherjee, none; A. Vidyarthi, none; S. Ranji, none; R. Wachter, none; R. Baron, none.

To cite this abstract:

Mookherjee S, Ranji S, Vidyarthi A, Wachter R, Baron R. Residents' Awareness of and Response to Medicare's Rule on Nonpayment for Hospital‐Acquired Conditions: A Little Knowledge Can Be a Dangerous Thing. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 72. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/residents-awareness-of-and-response-to-medicares-rule-on-nonpayment-for-hospitalacquired-conditions-a-little-knowledge-can-be-a-dangerous-thing/. Accessed May 26, 2019.

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