How Medicare Reimbursement Changes Affect Nurses


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How Medicare Reimbursement Changes Affect Nurses

In August, 2007, CMS, the Centers for Medicare and Medicaid Services, instituted reimbursement rules known as a “do-not-pay list” for which they will no longer pay hospitals for extra care fees involving several preventable conditions. On October 1, 2008, that list will expand to include two additional conditions.

The original set of preventable conditions includes:

  • Falls
  • Mediastinitis (an infection which can occur after heart surgery)
  • Urinary tract infections from improper use of catheters
  • Pressure ulcers
  • Vascular infections from improper use of vascular catheters

The list also includes three items better known now as “never events.” These are:

  • Objects left in the body during surgery
  • Air embolisms
  • Blood incompatibility (transfusing the wrong blood type)

The conditions being added to this list of preventable conditions are:

  • Blood clots in the leg after knee or hip-replacement surgery
  • Complications resulting from inadequate control of blood sugar levels

Along with these new conditions, CMS is expected to expand the “never events” list to include surgical site infection resulting from certain elective procedures.

CMS had been considering seven new items, but reduced the list to only two after careful consideration of concerns raised by the AMA and hospitals that quality of patient care could be reduced significantly at a time when concerted efforts are being made to preserve and improve quality of care.

CMS has recommended to the states that they adopt similar do-not-pay categories for Medicaid reimbursement. Many private health insurance companies have implemented similar rules for reimbursement and are expected to expand them to coincide with the changes Medicare is making now.

How does all this affect nurses?

One might expect that the hospitals would “wake up” and realize that they need to have better staffing ratios and working conditions, along with staff education so that nurses can ensure patients have the quality of care needed to prevent these complications. Studies have proven that nurse to patient ratios directly affect quality of care.

Continuing education is also important. For example, there has been much said in nursing literature recently about patients in the ICU developing pressure ulcers. With all the tubes and wires, it can be difficult to rotate positions. The problem however is that many nurses believe that the patient won’t be in that state long enough to develop a decub. But pressure ulcers can develop very quickly and especially in the very debilitated.

While it may be true that a patient doesn’t stay in the ICU long enough for the ICU nurses to have to treat a pressure ulcer, that time lying on their back 24/7 has set in motion an ulcer that will need to be treated on the medical floor and probably even at home after discharge. It’s only when risk management carefully tracks the data and provides feedback and education that the ICU nurses would even know that their patients developed the decubs from their ICU care.

More staff and better staff education would seem a natural order of progression in preventing the complications that result in reimbursement losses. In reality, more often than not hospital administrators have, and will likely continue to pressure nursing administration to put the responsibility on the staff nurses to improve the care and not offer much in the way of support.

How has your facility dealt with these changes in reimbursement?

By Kathy Quan RN BSN. Kathy is the author of The Everything New Nurse Book and the owner/author of

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