“A discussion on the ethics and finances of Medicare’s
refusal to pay for pressure ulcers
that develop in a hospitalized patient.”
“Pressure to Change”
Medicare like all health insurers is constantly looking for ways to avoid paying for unnecessary medical care. The latest attempt sounds perfectly reasonable until you consider who will bear the burden. Problem: Last year federal centers for Medicare and Medicaid Services announced that they would no longer reimburse hospitals for treatment of new pressure sores in Medicare patients. The ruling, known as the Inpatient Prospective Payment System (IPPS) final rule, adopts a new Medical Severity Diagnoses Related Group (MS-DRG) classification system that expands the current number of DRGs from 538-745, with weighing factors that will be phased in over a 2 year period. What does this all mean: Under the new payment plan, pressure ulcers present on admission will qualify for a higher reimbursement ONLY if the pressure of Stage III or IV ulcer is noted in the medical record within 2 days of inpatient admission. Anything identified after that initial admission period will not be eligible for additional reimbursement. Medicare’s rationale is that by refusing to pay for a “never event” it will reduce the number of mistakes. They claim that the “never event” is a mistake so easy to prevent that it should never happen. Don’t have Medicare and think this does not affect you, well it does, most private insures usually adopt Medicare rules eventually. However, Medicare still pays for errors on wrong site surgeries which seem like a “never event” that should top the list as PREVENTABLE! What are pressures and are they really preventable: The medical term Decubitus Ulcer, Decubitus mean’s “lying down” simply implies only a single etiology for these lesions, yet their pathogenesis also includes, at least, friction, shear force, moisture, temperature elevation, sensory impairment and oxygen deprivation. When you think of the word pressure ulcer, what might come to mind is “Neglect” and when you see how atrocious some pressure ulcers can become, the word “Neglect” takes on a new meaning. It’s not always about being neglected; some patients have preexisting conditions that predispose them to being candidate’s for acquiring pressure ulcers outside the realm of the word “Neglect” Have you considered these patients being at risk for the development of a pressure ulcer and they also top the list of not being able to heal if a pressure ulcer was to develop. * Patients with Peripheral Vascular problems- diabetes, HTN, Hypercholesterolmia, Smokers, Hypotension, Hypoxia * Gastro Disease patients – Anyone who has problems with Malabsorption, poor absorbtion of nutrients or patients with CDiff – diarrhea only takes 45 minutes to sit on the skin before skin breakdown starts to occur. * Malignancy patients- cancer patients develop weight loss and sometimes don’t absorb nutrients needed to keep skin from breaking down * End Stage Renal disease patients – Protein energy decrease and results in malnutrition, anorexia, muscle wasting and decreased wound healing. * Patients on life support measures like ventilators, tubes, catheters, IV tubing makes repositioning challenges. * Studies show that 3 hours on a stretcher waiting to be seen, and tissue wasting may already have begun. Hospitals are still learning about it and trying to identify under what, if any, circumstances these pressure ulcers can be rescued. Even with an increasingly sophisticated understanding of the pathogenesis of pressure ulcers recognizes both the intrinsic factors (the individual's health) and extrinsic factors (mechanical influences) that contribute to pressure ulcer formation. Disease processes such as diabetes, heart disease, renal disease, dementia, and malnutrition also enter the equation because they affect both the development and healing of pressure ulcers. Does Medicare...