Thursday, June 4, 2009

Falls as a Medicare No Pay

Hospitals receive no reimbursement from Medicare if a patient falls in the hospital. Falling is considered one of the 10 "no pay" events by Medicare. So if a patient is in the hospital for pneumonia, congestive heart failure and cellulitis of the leg and that patient climbs out of bed and falls...their care will not be reimbursed. Medicare believes falls are preventable and should "never happen."

Dr. Sharon Inouye is directer of the Aging Brain Center, Institute for Aging Research at Harvard Medical School and she has spoken out on the folly of including falls in the "no pay" list in the New England Journal of Medicine. She argues that falls cannot be completely prevented and the efforts to reduce them may actually cause more harm to patients.

Even with side rails up and the call button placed in her hand, it is not unusual for a sick elderly patient to try to crawl out of bed at night...fall. The only way to prevent this is to use restraints and tie the patient to the bed. Patients who are in restraints can become agitated or delerious. Some have died. There is a huge movement in the patient safety world to reduce the use of restraints by any means.

There are other ways to reduce the risk of falls and hospitals need to incorporate them. Certain medications should be avoided in the elderly. Beds should be lowered and there needs to be scheduled trips to the toilet. Nurses making rounds every hour is a best practice to check on the needs of the patient. Hospitals can hire sitters to ...well, just sit...with the squirreley patient at night. That increases hospital costs by $millions so it is a cost/benefit decision.

Despite the best efforts, falls will happen. AARP says one in three people over the age of 65 will fall each year. I have no problem with most of the items on the avoidable errors list, but is falling an error by the hospital? This one needs to go back to the drawing board and it is time to listen to the experts instead of the policy wonks.


shadowfax said...

It's not accurate to say:
So if a patient is in the hospital for pneumonia, congestive heart failure and cellulitis of the leg and that patient climbs out of bed and falls...their care will not be reimbursed.

The medical DRGs will still be reimbursed as usual. What this means is that any additional diagnostic codes related to the fall (a fracture, laceration, etc) will not be paid. This could be pricey, if there was, say a broken hip. Or if the fall extends the hospitalization by some number of days.

This principle applies to all the "never events" like catheter-acquired UTIs, DVTs, etc. The primary diagnoses still get reimbursed, but the add-ons don't.

Toni Brayer MD said...

Shadowfax: You are correct. Thanks

tracy said...

So, is it people (like my husband and my son and i) with insuranse, hardly making ends meet, in the worst financial shape of our lives, paying the medicade bills?

A PS Is this the blog where i read the Sarah Palin Quote "Polar Bears aren't endangered...they're just unlucky." Ha, ha, ha. Is that dumb or what?

ERP said...

I agree fully.

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