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CMS Announces Rule on Preventable Conditions in Medicaid

By Jane Norman, CQ HealthBeat Associate Editor

States will be expected to work harder on reducing or eliminating preventable conditions or injuries in their Medicaid programs under a final rule announced by the Centers for Medicare and Medicaid Services.

For some time, Medicare provider payments have been reduced or banned if, in certain cases, a patient's condition is considered reasonably preventable. It's part of a drive to increase quality in health care. Now this concept will be extended to Medicaid.

For example, Medicare will not pay a provider for "never events" like a surgery when a doctor erroneously performs a correct procedure but on the wrong body part, or a correct procedure but on the wrong patient. And Medicare won't cover any related hospitalizations.

Payments may be reduced for hospital-acquired conditions such as foreign objects left in patients after surgery, falls or catheter-associated urinary tract infections.

Under the health care law (PL 111-148, PL 111-152), the curb on payments for preventable conditions must also apply to Medicaid, the federal-state partnership to provide care for low-income Americans. States won't be allowed to pay providers including hospitals, doctors and other health care organizations if patients develop conditions that are deemed reasonably preventable.

Medicare's list of preventable conditions will be used as the basis for the Medicaid rule, though the regulation acknowledges that not all of them can be directly transferred to a younger Medicaid population. "While we have established Medicare as a baseline, we understand that states will, through their payment policies, appropriately address these differences," says the rule.

Donald M. Berwick, CMS administrator, said in a conference call with reporters that states will be given the flexibility to identify additional preventable conditions beyond a CMS list. He called the rule "an important step toward the health care system we deserve."

Cindy Mann, deputy administrator and head of Medicaid, said states are looking for ways to improve quality while reducing costs and some have already begun cutting back on payments to hospitals for preventable conditions. This rule will affect all states, she said.

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