One major issue that affects healthcare providers, insurers, regulators, and patients is illnesses that patients acquire while being in a healthcare facility. In many cases, those are preventable. However, costs associated with treating those as well as legal and ethical implications affect establishments. This paper aims to provide an assessment of HAC issue and its impact in the health insurer Anthem, discuss compliance of organizations, tools for improving the benchmark metrics, and recommendations.
Assessment of Compliance
The existing regulations regarding HACs are stated in the Deficit Reduction Act of 2005 and can be changed by the CMS. Anthem has a clear policy regarding HACs, which was developed based on the CMS requirements. Firstly, the Affordable Care Act “authorizes the Centers for Medicare & Medicaid Services (CMS) to make payment adjustments to applicable hospitals based on risk-adjustment quality measures” (“Hospital-acquired conditions and present on admission indicator reporting provision,” 2017, p. 2).
Thus, hospitals receive reimbursement disregarding the secondary diagnosis that could have been avoided by applying certain evidence-based practices. However, a secondary provider will receive payment if the condition was caused by the actions of a primary care establishment. While this helps Anthem avoid financial losses, it should be noted that HACs impact the satisfaction of patients. To overcome the issue, Anthem requires all providers to diagnose HACs using POA tool, which should be done upon discharge (“Reimbursement policy,” 2017).
This insurer rejects claims that do not include POA. In addition, the organization can carry out a clinical review or ask for additional information to determine the validity of claims.
Thus, the strategy that will help influence, monitor, and impact the number of HAC cases is a non-payment practice that allows insurers such as Anthem to reduce amounts of reimbursements and avoided payments for conditions that can have been prevented. Based on the information provided by CMS, it can be anticipated that the list of HACs would expand in the future to include other illnesses associated with improper care. Also, it is possible that the regulators will require hospitals to develop and implement strategies that target common HACs as a mandatory practice. Then, Anthem would have to ensure that its reimbursement policy incorporates these measures by monitoring the providers.
Tools and Best Practices
A particular approach applied by this insurer can help monitor risks and mitigate the adverse consequences of HACs. Agency for Healthcare Research and Quality (AHRQ) developed several strategies that can help medical personnel manage preventable conditions more efficiently, for instance, a toolkit to promote safe surgery (“AHRQ tools to reduce hospital-acquired conditions,” 2019). Those help ensure that medical personnel and hospital management work by standardized practices that were proven to improve treatment outcomes.
One approach is using the Agency for Health Care Research and Quality Patient Safety Indicators (PSIs) as a primary metric. Measures that would help improve these PSIs should result in better outcomes for the HAC cases. Additionally, the pay-for-performance approach is valid in this case as well. Waters et al. (2015) provide evidence suggesting that the implementation of HAC non-payment practice had a positive effect on the improvement of patient safety.
Thus, Anthem should continue developing strategies similar to this one that would encourage providers to dedicate more efforts towards risk reduction. According to O’Connor (2016), accountable care organizations (ACO) are successful at providing enhance the quality of care. Therefore, the organizational structure that can help improve these HAC measures should be based on the HAC approach and include departments that monitor quality and communicate with patients to assess their feedback.
The challenges that arise upon implementing these strategies include the inability to affect providers directly, unclear results of program implementation, and a large number of partners. It is evident that insurers do not have a direct impact on the quality of services provided to patients by healthcare establishments, which results in a difficulty when managing HAC-related risks. However, Wallace, Cropp, and Coles (2016) state “the true burden of all hospital-acquired infections really lies on those paying the final bill, health insurers” (para. 2).
The authors argue that in regards to infections acquired in hospitals, no existing evidence suggests that the pragmas implemented by the government and health care providers lead to a significant reduction of this HAC metric. Thus, the value proposition for change management at Anthem incorporates an emphasis on additional parameters, and ACO, which would help manage quality. Additionally, risk reduction will be facilitated through policies that require hospitals to emphasize patient safety.
Firstly, Anthem should invest in additional research to identify HACs that are most common among its providers. Next, it is necessary to encourage healthcare personnel to engage in the process of learning about measures that would prevent these illnesses. This can be done through a combined effort of Anthem and its partners. Finally, Anthem should revise its policy to ensure that other metrics, apart from POAs are included in the process of evaluation. Learning guidelines include a necessity to identify the conditions that can be affected by in-hospital policies.
In general, insurers can affect HAC outcomes by ensuring that the existing policies encourage providers to implement preventative measures. This can be done by emphasizing the need to work as ACO organizations and implementing practices and toolkits developed by AHRQ. In this way, Anthem can enhance patient care and manage risks connected to HACs. In addition, the insurer should invest in research that helps identify the policies that affect HACs.
AHRQ tools to reduce hospital-acquired conditions. (2019). Web.
Hospital-acquired conditions. (2018). Web.
Mission, vision and values. (n.d.). Web.
O’Connor, J. (2016). An ACO success story. McKnight’s Long-Term Care News, 37(1), 27.
Reimbursement policy. (2017). Web.
Wallace, N., Cropp, B., & Coles, J. (2016). Insurance companies pay the price for HAIS. Web.
Waters, T., Daniels, M., Bazzoli, G., Perencevich, E., Dunton, N., Staggs, V., … Shorr, R. I. (2015). Effect of Medicare’s nonpayment for hospital-acquired conditions. JAMA Internal Medicine, 175(3), 347. Web.
Table 1. Executive summary table (created by the author).
|Action Step||Relevant Data||Resource Information|
|1. Issue||Hospital-Acquired Conditions (HACs) are a category of illnesses that a patient acquires within a healthcare establishment. This issue is important because it results in lower revenue and increased legal risks.|
|2. Regulatory Requirements||Deficit Reduction Act of 2005 contains a list of HACs that are preventable when appropriate practices are in place. |
Inpatient Prospective Payment System (IPPS) provides information regarding payment provision of HAC-related conditions. Both allow insurers to develop reimbursement practices that target HACs.
|Deficit Reduction Act, |
Inpatient Prospective Payment System (“Hospital-acquired conditions,” 2018).
|3. Risk Management Implications||According to Wallace et al. (2016), those are ”significant post-discharge insurance claims related to medications, primary care follow-up, lab work, rehab and homecare” (para. 2).|
|4. Environmental Assessment||Strengths: |
The regulators such as the CMS and others provide evidence and tools that help providers reduce the number of HACs.
Health insurers do not directly affect the provision of services within healthcare settings.
(Waters et al., 2015).
Reduction of HACs is a regulatory requirement that can help improve revenue.
Failure to enhance policies may result in significant financial losses.
|5. Resources to Address the Issue||Anthem has a policy of removing charges that are connected to HACs from the payment claims. This organization uses categories identified by CMS and Present on Admission (POA) approach.|
|6. Philosophy or Culture Statement||In summary, Anthem aims to use innovation that is a necessary part of HAC improvement.||(“Mission, vision and values, ” n.d.).|
|7. Measurement and Monitoring||AHRQ toolkits and PSIs can be used for measurements and |
outcomes data can help examine the existing practices.
|(“AHRQ tools to reduce hospital-acquired conditions, 2019; O’Connor, 2016; Waters et al., 2015).|
|8. Organizational Improvement||Improved reimbursement policy can be used to encourage voluntary reporting.||(O’Connor, 2016).|
|9. Ethics Consideration||Legal implications include potential lawsuits from patients |
From an ethical perspective, quality improvement should be an implication for healthcare establishments.
|(“Creating an ethical culture within the healthcare organization, 2015).|