The Cms Policy on Venous Thromboembolism As a Hospital Acquired Condition: Projected Revenue and Cost Impact of Potential Expansion to Include Medical and Surgical Patients

Background:

The Centers for Medicare and Medicaid Services (CMS) executed a policy denying reimbursement for hospital‐acquired conditions (HACs)—“never events.” Venous thromboembolism (VTE) was identified as a HAC in patients undergoing total hip/knee replacement, partial hip replacement, or hip resurfacing as part of this policy in fiscal year 2009. This study estimated the projected financial impact of potential expansion of this policy, to include other surgical procedures and medical conditions associated with VTE risk, on U.S. hospitals in terms of increased costs and loss of revenue.

Methods:

Discharge data were extracted from the Thomson Reuters MarketScan® Hospital Drug Database for patients at risk of VTE undergoing “CMS‐defined” and “other” major hip/knee surgery, small/large bowel surgery, or hospitalized with chronic obstructive pulmonary disease, acute myocardial infarction, congestive heart failure, cancer or severe infectious disease. Inclusion criteria included admission/discharge between October 2007 and September 2008, age ≥ 18 years, Medicare primary payer, valid CMS hospital ID, and no evidence of VTE on admission. Frequency of CMS‐defined VTE was assessed, and the projected economic impact of potential expansion of the CMS policy estimated. The projected annual revenue loss per hospital was calculated using the existing CMS reimbursement rules and potential inclusion of other surgical procedures and medical conditions. The incremental cost impact—the additional hospital cost due to a VTE—was also analyzed.

Results:

Most of the 109 study hospitals (51.4%) were medium to large and nonteaching in urban areas. A total of 147,071 discharges were eligible for inclusion, 17.8% for “CMS‐defined” hip/knee procedures, 7.4% for other surgical procedures, and 74.8% for medical conditions. Under the current CMS policy, symptomatic VTE occurred in 1.1% of discharges, with a mean annual revenue loss per hospital of $8453. Potential expansion of the current policy led to a projected revenue loss of $42,889 for inclusion of other surgical procedures and $52,676 for medical conditions. Mean incremental cost per hospital for a discharge with VTE was $6581 for hip/knee procedures under the current CMS policy, $13,990 for potential expansion to other surgical procedures, and $6359 for medical conditions. Annually, these costs were projected to be $31,609, $104,492, and $137,460, respectively.

Conclusions:

The current CMS policy for VTE as a HAC in certain hip/knee procedures is associated with hospital revenue loss and increased hospital costs, which are projected to become substantially higher with potential expansion to other surgical procedures and medical conditions associated with VTE risk. If CMS were to expand its current policy in a similar manner to our hypothetical assumptions, these significant costs would no longer be reimbursed. Therefore, it is important that hospitals reduce VTE rates through appropriate prophylaxis of at‐risk patients.

Disclosures:

S. Deitelzweig ‐ sanofi‐aventis US Inc., Bristol‐Myers Squibb, Scios, honoraria, research funding, and speakers bureau; Pfizer, speakers bureau; S. Thompson ‐ sanofi‐aventis U.S. Inc., employment; J. Lin ‐ sanofi‐aventis U.S. Inc., employment and research funding; D. McMorrow ‐ sanofi‐aventis U.S. Inc., research funding; B. Johnson ‐ sanofi‐aventis U.S. Inc., research funding; all authors ‐ sanofi‐aventis U.S. Inc. 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