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Proposal to Widen Medicare Pneumonia Penalty Panned by Groups

By Kerry Young, CQ Roll Call

July 30, 2015 -- Medicare officials are encountering substantial backlash to their bid to broaden the hospital readmission penalty program to include a form of pneumonia that tends to occur in the most frail patients.

Groups including the American Geriatrics Society want the proposal dropped from Medicare's fiscal 2016 payment rule for care provided to people admitted to hospitals. The Centers for Medicare and Medicaid Services (CMS) is expected to soon unveil its final version of this rule, which it released in draft form in April. The annual inpatient hospital regulation will address dozens of policy issues regarding procedures. It also will change payment rates for services.

CMS wants to change the readmission penalty starting in fiscal 2017 to include cases of aspiration pneumonia, which occurs when food, liquid and vomit are advertently drawn into the lungs. Medicare officials argued that this change regarding pneumonia in the penalty program would "better represent the complete population of a hospital's patients" who are treated for the lung infections. Pneumonia with a root cause of bacterial and viral infections already are incorporated into the penalty program.

The American Hospital Association, the American Medical Association and the Association of American Medical Colleges are among the groups objecting to the proposed expansion. Aspiration pneumonia tends to occur when people have been so weakened by disease that their ability to swallow is affected, groups told CMS in comments on the payment rules. It's seen in people left debilitated by strokes as well as those suffering from dementia.

The leaders of the American Geriatrics Society told CMS that hospital staff might seek the wrong treatment for these patients in an attempt to avoid penalties.

"We fear that the unintended consequences of this policy would far outweigh the benefits," Steven R. Counsell, president of the group, and Nancy E. Lundebjerg, its chief executive, said in a June letter to CMS." This policy could lead to increased feeding tube placement (which does not decrease aspiration risk, according to the medical literature and expert opinions, but nonetheless is a local practice pattern in some parts of the U.S.)."

Previous hospital payment rules established a framework for the readmission penalty program, which was mandated by the 2010 health law (PL 111-148, PL 111-152). Other conditions weighed in the penalty calculations are heart failure and heart attacks. The program contributed to a reduction of about 100,000 hospital stays in 2013, according to recent testimony by the Medicare Payment Advisory Commission. 

CMS will respond to the objections made about the aspiration pneumonia proposal for the penalty program in the final version of the fiscal 2016 hospital payment rule that has been under review since July 24 by the Office of Management and Budget, which does a last check on federal regulations before they are released. 

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