HACs and "manifestations of poor glycemic control"   (October 2, 2008)

Years ago, I was sometimes frustrated to see that hospitals made occasional medication errors involving insulin and diabetes pills, but the errors got swept under the rug. For instance, if a patient got 100 times as much insulin as they should, due to sloppy physician handwriting in the orders, or to a hospital employee mistakenly entering information into a computer, and the patient developed hypoglycemic coma, it rarely attracted much attention.

But times have finally changed. The US Medicare program has just set a new requirement in place: under rules that took effect yesterday, October 1, hospitals will no longer be able to get extra Medicare dollars to fix their mistakes. The official pronouncement was announced in a press release this past summer:

The Centers for Medicare & Medicaid Services (CMS) announced [July 31, 2008] it is taking several actions to improve the quality of care in hospitals and reduce the number of "never events" -- preventable medical errors that result in serious consequences for the patient. "Never events cause serious injury or death to beneficiaries and result in unnecessary costs to Medicare and Medicaid due to the need to treat the consequences of the errors," said CMS Acting Administrator Kerry Weems. "The steps taken today reflect our strong conviction that these events, in fact, should be prevented, and our commitment to protecting Medicare and Medicaid patients from them."

The exact rule was published in the Federal Register on August 19, 2008 and lists several "hospital-acquired conditions" (HACs) that will not be reimbursed. One of the HACs relates to diabetes care: "Manifestations of Poor Glycemic Control"; these specific situations were ascertained to be non-reimbursable:

• hospital-acquired diabetic ketoacidosis (DKA)
• hospital-acquired nonketotic hyperosmolar coma (NKHC)
• hospital-acquired hypoglycemic coma

So, as of now, if a patient is in a hospital, and while hospitalized, the patient develops DKA or NKHC or hypoglycemic coma, the hospital is not going to be paid by Medicare/Medicaid for treatment of that condition. And other insurance companies will certainly follow the government's lead, and not pay, either.

What will happen? Well, if a patient develops any of these HACs, they will be cared for, but the hospital will have to swallow any costs associated with that condition. And I'd guess the case will be closely scrutinized by some hospital committee -- probably the hospital's Pharmacy and Therapeutics ("P&T") Committee -- to figure out what went wrong and how to prevent a recurrence.

And if there's a "systems problem" -- such as lack of training of hospital staff, it'll be fixed pronto. Or if there's one physician who is a repeat offender, he/she will be called on the carpet, and perhaps even have his/her hospital privileges revoked -- which could lead to suspension of his/her medical license.

All in all, I think it's a Very Good Thing to focus attention on the need for excellence in in-patient diabetes care. Sad that it took a financial "big stick" to get this attention, but I'm glad it's finally happened.