New Opportunities to Improve Pressure Ulcer Prevention and Treatment
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Implications of the CMS Inpatient Hospital Care Present on Admission (POA) Indicators/Hospital-Acquired Conditions (HAC) Policy
A Consensus Paper From the International Expert Wound Care Advisory Panel
As part of the Deficit Reduction Act of 2005, the Centers for Medicare & Medicaid Services (CMS) initially identified eight preventable adverse events on August 1, 2007, with nine more conditions proposed on April 14, 2008. 1,2 They have introduced a plan to help contain costs by rejecting payment of the higher diagnostic category when such events occur as a secondary diagnosis in acute care facilities. This policy, which began a phased rollout in the acute-care setting in October 2007 (culminating in October 2008), has created some logistical and implementation concerns in the clinical community. The financial implications for pressure ulcers will be determined by the Present on Admission Indicator (POA). The POA Indicator identifies if a patient has a pressure ulcer at the time the order for admission occurs.
Now there is a renewed urgency and heightened focus on prevention because beginning in October of 2008, the hospital will not receive additional reimbursement to care for a patient who has acquired the pressure ulcer while under the hospital’s care. Like any groundbreaking policy, this provides impetus for change. We view this payment provision as challenging, but one that provides all clinicians and particularly wound care specialists with an opportunity to assume leadership in important preventive healthcare strategies.
Pressure ulcers represent the possibility to implement best practices to improve outcomes. In FY 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses. 2,3 The average cost per case in which pressure ulcers were listed as a secondary diagnosis is estimated to be $43,180 per hospital stay. 2,3 The incidence of new pressure ulcers in acute-care patients is around 7%, with wide variability among institutions. 4
The Medicare program’s hospital inpatient prospective payment system (PPS), as currently set forth, will no longer assign a higher DRG for facility-acquired pressure ulcers effective October 1, 2008. 5 Physician/provider* determination and documentation during the hospitalization that the pressure ulcer was present at the time of admission is critical. Since this represents a change in approach from current skin assessment protocols, as well as a paradigm shift with financial implications, it requires some new approaches in terms of how healthcare professionals in the acute-care setting manage patients at risk for pressure ulcers or patients admitted with existing pressure ulcers. While physician/provider* documentation is required, the expertise of wound assessment in hospitals is predominantly within nursing. Competence of the provider in assessment is critical to do an accurate skin assessment.
History
Wound care has been discussed even in the most ancient of medical literature, dating back to the earliest known medical document, the Edwin Smith Papyrus (17th century B.C.). 6 Wound care, and specifically prevention and treatment of pressure ulcers, has always been an important component of clinical care. In the 19th and 20th centuries, pharmacological and technological innovation captivated the focus of medicine, and today’s evidence-based medicine continues the emphasis on drug- and device-based interventions. The result is that the prevention and treatment of pressure ulcers have been the subject of fewer retrospective studies and randomized clinical trials compared to many other areas of medical interest.
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2. Centers for Medicare & Medicaid Services. Proposed Fiscal Year 2009 Payment, Policy Changes for Inpatient Stays in General Acute Care Hospitals. Available at: http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3045&intNu.... Accessed: May 13, 2008.
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