Impact of CMS VTE Hospital Acquired Conditions (HAC) Policy on Hospital Cost and Revenue Associated with Major Surgical Hip and Knee Procedures.

The Centers for Medicare and Medicaid Services (CMS) recently executed a policy which denies reimbursement for preventable hospital acquired conditions (HAC) (“never events”). Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), in patients undergoing major surgical hip or knee procedures was a condition selected for implementation as part of this policy in fiscal year 2009 (beginning October 2008). The objective of this analysis was to estimate the financial impact of this policy change on US hospitals.

Discharge-level hospital administrative records were extracted from the Thomson Reuters MarketScan® Hospital Drug Database for patients undergoing CMS-defined surgical hip and knee procedures (total hip/knee replacement, partial hip replacement, and hip resurfacing). Discharged patients meeting the following criteria were included: admission and discharge between October 2007 and September 2008, age ≥ 18 years, Medicare as primary payer, valid CMS hospital ID and no evidence of DVT/PE on admission. The frequency of CMS defined VTE was assessed and the economic impact of the CMS HAC policy was estimated. Revenue impact, the amount of revenue lost per hospital due to CMS policy implementation, was calculated per year and per VTE discharge using the old and new CMS reimbursement rules. The incremental cost impact, the additional cost to hospitals due to VTE among hip/knee surgery patients, was also determined.

A total of 107 hospitals were identified to have at least one eligible surgical hip and knee surgery discharge. The total number of such discharges was 26,144. On average, there were 244.34 CMS-defined hip/knee surgery discharges per hospital. The majority of discharged patients were from urban hospitals (83.37%) in the Southern US (73.07%), without teaching status (87.98%) and with a licensed bed size of 300–499 beds (31.90%). VTE occurred in an average (± standard deviation) of 4.25 ± 6.05 hip/knee surgery discharges per hospital; DVT and PE occurred in 2.44 ± 5.11 and 1.81 ± 1.89 discharges per hospital, respectively. The average length of hospital stay was 7.56 ± 2.88 days in hip/knee discharges with VTE, compared to 4.08 ± 0.59 days in discharges without VTE. Anticoagulation was ordered in 94.70% of discharged patients with DVT and in 89.06% of discharged patients with PE. Under the CMS HAC policy for VTE, the mean loss of revenue per hospital per year was estimated to be $8,453 (95% confidence interval [CI] 6,902 – 10,005). Per VTE, the average hospital revenue loss was $2,704 per hospital per year. The mean incremental cost for a hip/knee discharge with VTE, per hospital was $6,581; for DVT and PE, incremental cost impacts were $6,751 and $8,092, respectively. The annual cost impact per hospital for hip/knee discharges with VTE was estimated at $31,609 [95% CI 23,714 – 39,505].

The CMS policy on average caused a loss of hospital revenue (≂f$8,500 per year). Additionally, when a VTE event does occur in patients undergoing surgical hip and knee procedures, it is associated with high incremental hospital costs (≂f$32,000). These significant costs will no longer be reimbursed under the new CMS HAC policy. Subsequently, hospitals will be responsible for covering them. Therefore, now more than ever, reducing VTE rates through appropriate prophylaxis of at-risk patients is vital in order for hospitals to lessen the economic impact associated with treating VTE events. The drive to encourage hospitals to provide more efficient and effective healthcare is becoming particularly relevant now that models of health care reform, such as the “Accountable Care Organization”, are being piloted as part of the Senate's Healthcare Reform Bill.

This study was funded by sanofi-aventis U.S., Inc. The authors received editorial/writing support in the preparation of this abstract provided by Katherine Roberts, PhD of Excerpta Medica, funded by sanofi-aventis U.S., Inc.

Deitelzweig:sanofi-aventis: Honoraria, Research Funding, Speakers Bureau; Bristol-Myers Squibb: Honoraria, Research Funding, Speakers Bureau; Scios: Honoraria, Research Funding, Speakers Bureau; Pfizer: Speakers Bureau. Thompson:sanofi-aventis US Inc.: Employment. Lin:sanofi-aventis US Inc.: Employment, Research Funding. McMorrow:sanofi-aventis US Inc : Research Funding. Johnson:sanofi-aventis US Inc: Research Funding.