The Centers for Medicare and Medicaid Services' Nonpayment Policy and Nursing Sensitive Patient Outcomes in the U.S. Hospitals

Saturday, 26 July 2014

Sung-Heui Bae, PhD, MPH, RN
School of Nursing, University of Texas at Austin, Austin, TX


The Centers for Medicare & Medicaid Services (CMS) implemented a new policy for Medicare in 2008 to reduce preventable adverse outcomes in hospitals. The new CMS reimbursement policy incentivizes the prevention of avoidable adverse patient outcomes by eliminating reimbursement for treatment of those outcomes in hospitals (Department of Health and Human Services, 2009). Intended consequences of the new CMS policy include appropriate changes in care processes to foster better quality of care so that hospitals can prevent adverse outcomes. However, there are also concerns about possible unintended consequences of such a financial program, including avoiding admissions of patients with higher acuity levels and resource shifting to focus only on the targeted adverse outcomes (Hart-Hester et al., 2008; Hartley, 2004). However, researchers have not yet examined the implementation of such policy focusing on nursing sensitive outcomes and factors related to better implementation. Therefore, the current study examined the impact of the new CMS nonpayment policy on nursing sensitive patient outcomes.


The current study used data from the 2010 American Hospital Association Annual Survey data, Hospital Compare data from CMS, and the Rural-Urban Commuting Area code (RUCA) data based on Census commuting data and zip codes. This study focused on 4 nursing sensitive patient outcomes: (1) stages III and IV pressure ulcers, (2) falls and trauma, (3) catheter-associated urinary tract infections (CAUTI), and (4) vascular catheter-associated infections (VCAI). The variation of the implementation of the CMS policy was measured by the proportion of hospital discharges paid by Medicare as a proxy. We also examined factors contributing to better implementation, including region, size, ownership, teaching status, length of stay, RN staffing, and case mix. The final analytic sample consisted of 3,260 U.S. hospitals.


In 2010, pressure ulcer stages III and IV occurred 0.106 per 1,000 discharges paid by Medicare. Falls and trauma and CAUTI occurred 0.556 and 0.304 per 1,000 discharges. On average, 0.282 VCAI per 1,000 Medicare discharges were reported. In further analyses, we will test what extent all of these nursing sensitive patient outcomes are related to the implementation of the CMS nonpayment policy and factors related to better implementation. 


The study finding will provide critical information regarding the implementation of the new CMS nonpayment policy and nursing sensitive adverse outcomes. Especially, it will provide which hospitals are at risk to prevent those adverse outcome and to adjust themselves to this new budget constraint. As the policy of nonpayment for preventable adverse patient outcomes to Medicare will be expanded through the Affordable Care Act, the study findings will provide critical information regarding the effect of this program on nursing sensitive patient outcomes.