In October 2008 the Centers for Medicare & Medicaid Services (CMS) discontinued additional payments for preventable hospital-acquired conditions (HACs), which according to the American Society for Healthcare Risk Management, included:
- Vascular-catheter-associated infection
- Catheter-associated urinary tract infection
- Pressure ulcers (stage III and IV)
- Falls and trauma
- Surgical site infection after bariatric surgery for obesity
- Certain orthopedic procedures
- Bypass surgery (mediastinitis)
- Administration of incompatible blood
- Air embolism
- Foreign object unintentionally retained after surgery
“The idea was that the infections are avoidable, and hospitals should not be paid more money for providing faulty care.” Four years after doing so, a recent study published in The New England Journal of Medicine found that the policy has had “no effect on curbing infections.”
Although the policy only cut back an average of six-tenths of a percent of Medicare revenue, according to The Boston Globe, it was a high-profile policy change toward a pay-for-performance approach to reimbursement.
Researchers looked specifically at data from 2006 through 2011 from 398 hospitals in 41 states on central catheter-associated bloodstream infections and catheter-associated urinary tract infections and compared infection data against rates of ventilator-associated pneumonia, which is not under the nonpayment policy.
The result: Researchers found “no evidence that the 2008 CMS policy to reduce payments for central catheter-associated bloodstream infections and catheter-associated urinary tract infections had any measurable effect on infection rates,” study authors wrote. The results did not “appear to be affected by whether the hospitals were in states that required reporting of such infections or by other hospital characteristics, such as size, share of patients on Medicare or ownership,” the study’s authors wrote.
What this might suggest is that government threats for penalties may be the wrong approach. Instead, it may be more useful for the government to invest in educational resources, such financial support for continuing education (CE) programs, which have proven effective in helping improve HACs.
Although infections rates have generally dropped since 2006, it was not because of the Medicare penalties, U.S. News and World Report’s HealthDay reported. “It had really nothing to do with the CMS policy,” Grace Lee, associate professor at Harvard Pilgrim Health Care Institute and Harvard Medical School, told The Boston Globe. Lee added that the CMS policy “may not have been enough to motivate further change of behavior.”
Infection rates were already dropping without the CMS policy because hospitals were taking steps to control infections through improvements such as rigorous coding procedures, which may demonstrate better administrative skills rather than better quality, HealthDay noted.
In addition, many of those 398 hospitals were voluntarily reporting that data even before the payment policy was implemented, which means they may have been further ahead in their infection control efforts than others, thus resulting in no additional slowdown after the penalties, says Lisa McGiffert of Consumers Union, publisher of Consumer Reports.
The results of this study may trouble hospitals facing penalties for readmissions, which CMS began assessing this month. For example, American Hospital Association Vice President Nancy Foster told The Wall Street Journal that the study should make policy makers “take a step back and say, ‘Are payment penalties the right way to go; do they actually add to the efforts?’ on reducing infections and other hospital-acquired conditions?”
Foster told Kaiser Health News that a key piece of any effort to reduce hospital infections is not just to count the number of patients who have problems, but to have a specific, detailed prevention strategy. Preliminary results from the association study found a 40 percent reduction in central line-associated bloodstream infections in intensive care units when they used a team-based approach.
CMS said, “Taken all together, our policies are working” to reduce infections patients get while in the hospital. The agency pointed to other efforts, including one program funded by the federal Agency for Healthcare Research and Quality that was tied to a 40% decrease in the rate of the catheter-linked bloodstream infections in hospital intensive-care units.
Dr. Jeffrey Rothschild, an associate physician at Brigham and Women's Hospital in Boston, suggested that the findings are not unexpected. “This is a really difficult thing to study, because often the data and discharge coding concerning hospital infections doesn't actually reflect what’s really happening,” Rothschild said.
Back in June of this year, HHS posted online an updated National Action Plan to eliminate healthcare-associated infections for public comment. The update confirmed progress in the effort to make healthcare safer and less costly by reducing preventable complications of care, including healthcare-associated infections (HAIs). This new study, however, may cast down on this progress.
HHS, however, also laid out its new plan to address HAIs through its Partnership for Patients. This program may have the potential to address the study’s findings, although the success of the Partnership is too soon to predict.
While the results of this study cause concern, the Affordable Care Act and the Obama Administration’s stance on improving quality will remain, and government agencies and private insurers will continue to tie payment to quality measures. For example, beginning in 2015, CMS “will begin financially penalizing hospitals that have the highest rates of certain hospital-acquired health conditions,” reported WSJ.