Potential Unintended Consequences Due to Medicare's "no Pay for Errors" Rule? A Randomized Controlled Trial of an Educational Intervention with Internal Medicine Residents

Background: Medicare has selected 10 hospital-acquired conditions for which it will not reimburse hospitals unless the condition was documented as "present on admission." This "no pay for errors" rule may have a profound effect on the clinical practice of physicians.

Objective: To determine how physicians might change their behavior after learning about the Medicare rule.

Design: We conducted a randomized trial of a brief educational intervention embedded in an online survey, using clinical vignettes to estimate behavioral changes.

Participants: At a university-based internal medicine residency program, 168 internal medicine residents were eligible to participate.

Intervention: Residents were randomized to receive a one-page description of Medicare's "no pay for errors" rule with pre-vignette reminders (intervention group) or no information (control group). Residents responded to five clinical vignettes in which "no pay for errors" conditions might be present on admission.

Main Measures: Primary outcome was selection of the single most clinically appropriate option from three clinical practice choices presented for each clinical vignette.

Key Results: Survey administered from December 2008 to March 2009. There were 119 responses (71%). In four of five vignettes, the intervention group was less likely to select the most clinically appropriate response. This was statistically significant in two of the cases. Most residents were aware of the rule but not its impact and specifics. Residents acknowledged responsibility to know Medicare documentation rules but felt poorly trained to do so. Residents educated about the Medicare's "no pay for errors" were less likely to select the most clinically appropriate responses to clinical vignettes. Such choices, if implemented in practice, have the potential for causing patient harm through unnecessary tests, procedures, and other interventions.