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Management Issue 4:
Patient Safety and Quality of Care

Why This Is a Challenge

As a purchaser of health care for over 100 million Americans, the Department faces challenges in ensuring the quality of care rendered to federal health care program beneficiaries. Despite increased attention to patient safety, quality problems persist. According to the Joint Commission, 40 wrong-site surgeries are performed in U.S. hospitals and surgicenters every week. OIG has found that 13.5 percent of hospitalized Medicare beneficiaries suffered harm from adverse events during their hospital stays. Forty-four percent of these adverse events were preventable and were caused by care failures, such as medical error, substandard care, or inadequate monitoring. Other OIG work has raised concerns about overmedication of beneficiaries with antipsychotic drugs in nursing homes; more than 20 percent of antipsychotic drugs claims for Medicare patients in nursing homes exceeded Medicare limits on dose or duration. OIG has also identified concerns with the licensure and qualifications of health care providers across all settings of care. In addition, for more than 60 percent of claims, hospices did not meet federal requirements for establishing adequate plans of care.

OIG investigations have uncovered instances and systemic patterns of substandard care in nursing homes. Problems often include inadequate staffing resulting in substandard care, failure to provide adequate nutrition and hydration, patients' developing preventable or untreated pressure wounds (bedsores), and other serious deficiencies.

Progress in Addressing the Challenge

The Department has taken steps to improve quality of care and promote patient safety. These includes targeting specific populations, such as improving coordination of care for Medicare beneficiaries with multiple chronic conditions, as well as improving care for all beneficiaries. The Department has committed up to $1 billion in ACA funding to the Partnership for Patients Initiative, a public-private partnership designed to keep patients from becoming injured or sicker and to help patients heal without complication. Members of the partnership will identify specific steps they will take to reduce preventable injuries and complications in patient care. Two specific goals set by the partnership are to reduce hospital readmissions by 20 percent and reduce preventable harm to hospital patients by 40 percent.

The Department is implementing value-based purchasing (VBP) payment policies required by the ACA, such as the policy establishing the new VBP program for hospitals that will include quality metrics, as well as other payment policies targeting improved quality, such as the hospital-acquired conditions policy. These policies provide incentives to deliver better care. The Department continues to promote the adoption of electronic health records (EHR) and electronic prescribing, which should improve quality of care, reduce medication errors, and otherwise promote patient safety. It established tools to help beneficiaries compare facility-specific quality indicators and inform their decisions regarding where to seek treatment. CMS is developing new programs, such as the Medicare Shared Savings Program, as well as demonstration programs sponsored by the new Center for Medicare and Medicaid Innovation, with potential to enhance provider accountability for quality of care and improve coordination of care and care transitions.

OIG has entered into corporate integrity agreements with several nursing homes and other health care providers, including hospitals, assisted-living facilities, and dental clinics, which include quality-monitoring provisions. CMS and OIG continue to work closely with law enforcement partners at the Department of Justice and through the Federal Elder Justice Interagency Working Group to pursue providers that subject elderly persons to abuse or neglect, to exchange ideas, and to promote policies advancing better care for the elderly.

What Needs To Be Done

The Department should continue to prioritize quality of care and patient safety and build upon its past efforts, including implementing the quality improvement provisions of the ACA and achieving the goals set by the Partnership for Patients. OIG has offered recommendations to assist the Department in this mission. For example, OIG suggested enhancements to nursing home oversight to ensure that Medicare does not pay nursing homes to overmedicate or otherwise inappropriately medicate beneficiaries. OIG also suggested enhancements to outpatient prescription drug claims that could help the Department ensure that Medicare and Medicaid beneficiaries receive only the drugs that are appropriate for their medical indications.

Further work also needs to be done to improve the quality of care rendered to patients in hospitals. For example, the Department could strengthen its hospital-acquired conditions policy, such as by improving compliance with present-on-admission coding rules and, if supported by evidence of effectiveness, expanding the list of hospital-acquired conditions. It should also continue denying payments for services of such low quality that they are virtually worthless and exclude providers that have rendered grossly substandard care, thereby preventing harm to additional beneficiaries. The Department must also ensure that health care professionals working in all sites of service, such as hospitals, nursing homes, school-based facilities, and even the beneficiaries' own homes, meet qualification and licensure requirements before they treat federal health care program beneficiaries.

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