Since the Centers for Medicare & Medicaid Services (CMS) began to refuse reimbursement to hospitals for hospital acquired stage III/IV pressure ulcers labeled “never events,” there has been considerable controversy surrounding the subject.
Stage III/IV pressure ulcers are serious wounds that are very expensive to treat, some cases costing upwards of $70,000. Not only has CMS refused to pay for the treatment of these events, private insurers have followed suit as well. Additionally, hospitals are prohibited from passing the costs on to the patients of their families.
Compounding the high costs, late stage decubitus ulcers occur relatively frequently. The National Pressure Ulcer Prevalence Survey showed that late stage decubitus ulcers occurred in approximately 0.65% of all patients in US acute care hospitals on average.
Are Decubitus Ulcers 100% Preventable?
The source of the controversy is from the concept that some experts believe that not all decubitus ulcers are preventable, regardless of the usage of best practices and technology. Lee Ann Krapfl, a wound care nurse and recent public policy committee chair of the Wound, Ostomy and Continence Nurses Society, notes that CMS itself has stated not all decubitus ulcers are preventable. In the long term care setting, CMS states, “a resident who enters the facility without pressure sores [must] not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable.”
According to CMS, “unavoidable” means: “the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of interventions; and revised the approaches as appropriate.”
Obviously, this seems to conflict with CMS’s policy regarding reimbursement of never event decubitus ulcers. However it must be noted that this ruling is for long term care facilities, and it may well be that CMS is holding acute care facilities to a higher standard of care.
Incidentally, should CMS decide to change its stance on decubitus ulcers in acute care hospitals, there is a good chance it will place the burden of proof regarding the avoidability of a decubitus ulcer incident on the hospitals.
Regardless of the setting, experts agree that decubitus ulcer prevalence can be reduced significantly using best practices and technology. Also, although experts disagree on the topic of unavoidable pressure ulcers, most agree that they are very rare if they exist.
FILED UNDER BLOG · TAGGED WITH CENTERS FOR MEDICARE & MEDICAID SERVICES, DECUBITUS ULCERS, NATIONAL PRESSURE ULCER PREVALENCE SURVEY, NEVER EVENTS