The OIG Report That Might Go Unnoticed or Simply be Ignored

OIG claims 25% of Medicare beneficiaries experienced adverse effects during their hospitalization in October 2018.

As usual this week I want to write about a U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit that many have simply ignored. We’ve all begun to dismiss the OIG’s reports as hyperbolic, based on findings by reviewers with inherent conflicts of interest. So, when the OIG recently published a study of adverse events, it received little attention – but we really should pay attention to this one.

Let’s look at what the OIG did. The agency looked at 834 eligible discharges and any associated 30-day readmissions from October 2018. The sample covered only 629 of the approximately 5,500 hospitals in the U.S. Let’s put that into perspective for a minute. There were 1,076,344 Medicare patients discharged during October 2018. Even if all the 834 discharges were associated with some form of adverse event, that would represent an occurrence rate of 0.08 percent, or 8 per 10,000 discharges, in a combined, unselected population. 

Examples of the “unevenness” of the sampling can be found in a 20-page appendix. Several cases were intracranial or cerebrovascular procedures. One case was a lung transplant. These procedures are not available at many Inpatient Prospective Payment System (IPPS) acute-care hospitals. This kind of selection bias makes the results appear maximally unfavorable to all providers.

Nurse screeners reviewed records using the Institute for Healthcare Improvement’s global trigger tool and assessed present-on-admission (POA) indicators. Nurses discovered 393 qualifying records. A team of six physicians then reviewed the records and found 299 related issues: 115 adverse events and 185 temporary harm events. Real quick, that gives an incidence of 0.03 percent, or 3 per 10,000 discharges.

The largest category was medication-related events, at 43 percent of the sample. Patient care events were 23 percent of the total; the most significant components in this group were skin injuries and falls. The next category was surgical, at 22 percent. Interestingly, over half of the events in the surgical category were determined to be not preventable. Finally, infection was 11 percent of the events.

The study is biased, and probably uninterpretable. So, why am I even talking about it? Three reasons. First, the OIG will tout it as finding that 25 percent of patients experienced harm, much of which was preventable. Second, the report includes IPPS and non-IPPS claims. That means it includes costs to Medicare Advantage (MA) plans. Third, buried on page 289 of the report is the claim that “we estimated the costs for all events to be in the hundreds of millions of dollars for October 2018.” That’s an annualized amount of over $1 billion. The Centers for Medicare & Medicaid Services (CMS) concurred, with a recommendation to broaden the lists of hospital-acquired conditions (HACs). The MA plans will almost certainly respond with aggressive attempts to reduce payments for preventable harm.

So, what should providers do to prepare?

  • First, be scrupulous about diagnoses. Many of the medication events cited in the report were related to “delirium” or other acute mental status changes. Several events related to acute kidney injury. We see encephalopathy, delirium, and acute kidney injury (AKI) reliably denied by payors and contractors. You’re going to be penalized for them, so make sure they’re accurate.
  • Second, plan for medication errors to be aggressively reviewed. Don’t document an association between a medication and an event unless you’re certain they’re related. And explain when they’re unrelated.
  • Third, pursue POA status, especially for skin care and infections. Don’t just pull up a template and click the normal boxes.

The OIG just handed CMS and MA a new playbook.

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John K. Hall, MD, JD, MBA, FCLM, FRCPC

John K. Hall, MD, JD, MBA, FCLM, FRCPC is a licensed physician in several jurisdictions and is admitted to the California bar. He is also the founder of The Aegis Firm, a healthcare consulting firm providing consultative and litigation support on a wide variety of criminal and civil matters related to healthcare. He lectures frequently on black-letter health law, mediation, medical staff relations, and medical ethics, as well as patient and physician rights. Dr. Hall hopes to help explain complex problems at the intersection of medicine and law and prepare providers to manage those problems.

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