Clinical Geriatrics

This is Part I of a two-part series on pressure ulcers and Medicare reimbursement. Part II will discuss documentation of altered skin integrity and will appear in the next issue of the Journal.

Introduction
Medicare recently announced that as of October 2008 it will no longer reimburse hospitals and nursing homes for preventable complications; included in this list of complications are pressure ulcers.1 But who will pick up the cost, and how will Medicare determine which pressure ulcers were preventable? Healthcare facilities stand to lose millions of dollars when pressure ulcers develop in patients under their care. This situation will become more challenging for hospitals if private insurers follow the example set by Medicare. This article will review specific factors that Medicare and other insurers may consider when determining whether a pressure ulcer is preventable—a decision that will have serious financial repercussions for all organizations that provide primary care for older persons.

The new Medicare reimbursement rules reflect the surge in interest for “pay for performance,” which encourages payment only for healthcare that meets certain benchmarks of quality.2 This concept has its basis in getting value commensurate with cost, and targets measures of performance such as quality, efficiency, and patient satisfaction—which in turn translates into absence of preventable errors or complications.3 In-hospital preventable occurrences include such entities as pressure ulcers, catheter infections, transfusion with incompatible blood products, fall-related injuries, and wrong-site surgery. In the past decade, healthcare quality advocates such as the Centers for Medicare & Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Quality Forum (NQF), and others have endorsed the concept that pressure ulcers are directly linked to quality. Denial of payment for pressure ulcers and related complications will essentially reward institutions with low ulcer rates, providing huge incentives to prevent this complication.

The prevalence of pressure ulcers in acute care hospitals ranges from 3.0% to 15%, with most patients being elderly, and the total national cost for treatment is conservatively estimated as between $5 billion and $8.5 billion.4,5 Pressure ulcers are the most common entity on the “no-pay” complications list. In 2006, CMS found 322,946 episodes of pressure ulcers occurring as secondary diagnoses on hospital charts, which was ten times more common than the next most prevalent complication, Staphylococcus aureus sepsis.6 Costs of pressure ulcers can be measured in additional nursing time, physician visits and consultations, prolonged hospital stay, diagnostic and operative procedures, wound care products, increased need for rehabilitation services, pain and debility, and death from related complications. All experts agree that the costs of treating pressure ulcers are much greater than the costs of prevention.5