June 20, 2005

Update on Quality of Care Study by OIG

A recent OIG study concluded that while the majority of consecutive inpatient stays at acute care hospitals (rehab units, psychiatric units and skilled nursing swing beds) were medically necessary, approximately 20% of the sequences were associated with poor care or fragmented services leading to multiple admissions. The expenditures due to these sequences to Medicare is estimated to be $267 million.

Quality of care problems include:
- failure to treat patients in a timely manner;
- inadequate planning; and
- inadequate monitoring and treatment.
In addition to quality of care issues for multiple stays, the OIG estimates that 10% of individual stays involves problems with the quality of care. An additional 3% of admissions are thought to involve inappropriate admissions and treatment, improper treatment facility or premature discharge.

Unnecessary fragmentation of services involves giving services that are medically necessary but in a manner that leads to an increased number of stays.

The OIG recommends that CMS take the following actions to address the aforementioned issues:
1. Direct Quality Improvement Organizations (QIOs) to monitor the quality of inpatient services provided within a sequence at these types of facilities.
2. Instruct QIOs and fiscal intermediaries to monitor medical necessity of these stays during consecutive sequences.
3. Reinforce efforts to educate providers about the proper uses of skilled nursing swing beds.

The CMS agreed with the findings of the study, but believed that existing systems already covered most of the OIG's recommendations. CMS will put together an article that will address the OIG's third recommendation for increased education on the appropriate uses of skilled nursing swing beds.

We can only hope that the OIG doesn't change the requirements again.