OIG Report On Medicare Statistics For Nursing Home Adverse Events And Associated Costs

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MedicalMalpracticeLawyers.com recently blogged about the DHHS Office of Inspector General's February 2014 report concerning the eye-opening Medicare statistics regarding the prevalence of preventable adverse events in skilled nursing facilities and nursing homes that cost Medicare billions of dollars every year.

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Medicare wastes billions of dollars each year on medical care required as a result of preventable nursing home injuries

In its February 2014 report entitled, "Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries," the U.S. Department of Health and Human Services Office of Inspector General ("OIG") reported on its medical records review of 362 Medicare beneficiaries conducted by five contracted physicians that was based on a random sample of 653 Medicare beneficiaries who met the following criteria: they had been discharged from hospitals to skilled nursing facilities ("SNF") for post-hospital care and arrived at the SNF within one day from discharge from the hospital; they had SNF stays of 35 days or less (which represents 70% of all Medicare beneficiary stays in SNFs); and, their SNF stay ended in August 2011. There were 100,771 Medicare beneficiaries who met the criteria.

A "SNF" is defined as a facility engaged primarily in providing skilled nursing care and rehabilitation services for residents who require such care because of injury, disability, or illness. 90% of SNFs are dually certified as both SNFs and nursing homes (i.e., long-term care providers). In 2011, there were 15,207 SNFs in the United States and 20% of all hospitalized Medicare beneficiaries went to a SNF in 2011. Medicare Part A pays for up to 100 days of care in SNFs per benefit period. Medicare beneficiaries are eligible for SNF stays following a hospital stay of at least 3 days when a medical professional verifies the need for nursing care and rehabilitation related to the hospitalization.

The OIG reported that more than one-in-five (an estimated 22%) of the Medicare beneficiaries experienced adverse events during their SNF stay. An "adverse event" is defined as harm resulting from medical care, including the failure to provide needed care. The OIG classified the adverse events into three clinical categories: events related to medication (37%), events related to ongoing resident care (37%), and events related to infections (26%).

The OIG further reported that an additional 11% of Medicare beneficiaries experienced temporary harm events during their SNF stay. A review of the adverse events and the temporary harm events by physician reviewers determined that 59% were clearly or likely preventable (69% of adverse events were preventable and 46% of temporary harm events were preventable) and much of the preventable harm was due to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care.

The physician reviewers determined that 66% of medication events were preventable, 57% of resident care events were preventable, and 52% of infection events were preventable. Among preventable events, 37% involved inadequate monitoring of the residents and 25% involved failure to provide necessary treatments.

The OIG estimated that 10,742 SNF residents experienced at least 1 temporary harm event during the study month and an estimated 2,154 of them had more than 1 unrelated event. Additionally, an estimated 21% who experienced adverse events also had temporary harm events during their stay.

More than 50% of the residents who experienced harm returned to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011 alone (of which $136 million was spent on hospitalizations associated with preventable events), which would mean that $2.8 billion was spent on hospital treatment for harm caused in SNFs in FY 2011. The $208 million represents 2% of the $10.2 billion that Medicare spent on inpatient hospital stays in August 2011.

The OIG estimated that 1,538 SNF residents experienced adverse events that contributed to their deaths during the study month and further estimated that 3,986 SNF residents experienced cascade events (an event that included a series of multiple, related events) during the study month.

The OIG identified a number of problems with the quality of care provided in nursing homes that include inadequate discharge planning and lack of compliance with CMS standards regarding the use of atypical antipsychotic drugs, sometimes resulting in hospitalizations and increased Medicare costs.

Medicare expenditures for SNF care more than doubled from 2000 to 2010: Medicare paid $12 billion for SNF care in 2000 and $26 billion in 2010. In FY 2011, Medicare paid $28.4 billion for SNF services provided to 1.8 million beneficiaries.

In a series of prior studies that resulted in 11 OIG reports regarding adverse events in hospitals from 2008 through 2012, it was found that 27% of hospitalized Medicare beneficiaries experienced adverse and temporary harm events and that 44% of the events were preventable. The care associated with such events costs the Medicare program an estimated $4.4 billion a year.

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