Under new rules slated to go into effect in October 2008, the Centers for Medicare and Medicaid Services (CMS) will stop reimbursing hospitals for additional treatments associated with some hospital-associated infections (HAIs) and medical errors.
Target areas include some catheter-induced urinary tract and vascular infections, mediastinitis associated with coronary artery bypass graft surgery, bed sores, surgical devices accidentally left in patients after an operation and air embolisms.
The goal of the CMS decision is to increase hospital vigilance, which ultimately may result in better patient care, says Tammy Lundstrom, M.D., a member of the Association for Professionals in Infection Control and Epidemiology (APIC), Washington, D.C., and chief medical officer for Providence Hospital, Southfield, Mich. But even the most diligent adherence to the latest evidence-based practices won’t completely free hospitals from HAIs and the added financial costs brought on by the new rules, Lundstrom adds.
Q Do you think the CMS decision will provide further incentives for hospitals to work harder at preventing HAIs?
A I certainly hope so; at least that’s the way it was intended. But concerns from the infection control community include the fact that not all these infections are preventable 100 percent of the time, even with the best evidence-based practices. It’s really not possible with the current state of the science.
Q So in some cases, do you think this is an unachievable goal for hospitals?
AWe can get to zero in a lot of cases. We’ve shown in the Michigan Keystone ICU project and others that we often can get to zero. But we can’t always get to zero with the full implementation of the evidence-based practices.
Q Are there specific kinds of infections that are impossible to eradicate completely?
A At my previous employer, we got to zero for bloodstream infections for many months at a time. And with ventilator-associated pneumonia for two to three months at a time. We were doing everything we should have to prevent the infections, but [eventually] one occurred. The patient state often influences the risk for infection. For example, burn unit patients have a much higher infection risk because the skin is one of our major defenses against infections. Bone-marrow transplant patients are more susceptible to infections. There are patient factors that are not always within our control. So the message from the professional societies in infection control is that zero is not always possible, but is at least possible a large portion of the time. And we have to continue to strive to follow all the evidence-based practices with every patient every day. Infection control is everybody’s responsibility in the hospital, not just the responsibility of a department, because everybody who puts hands on a patient has a role to play in infection control. Those cultural changes are helpful, and hopefully some of the CMS new payment policies will help to continue to drive that message.
It’s just that with the altered reimbursement, is it really equitable not to pay hospitals when they have done everything that is science based to prevent an infection and the patient still acquired one?
Q Do you think hospitals will be turning to additional or new technologies to help them control HAIs?
A I think that’s crucial. For example, information technology can help us in [disease] surveillance, data mining and other capabilities to make [infection control] more efficient and effective. New products are coming out for infection control that, hopefully, will add to the evidence-based literature to help us reduce infections further. We’re seeing such unique things as antibiotic-coated sutures, antibiotic-coated dressings and the continued evolution of antibiotic-coated devices to prevent infection.
There’s a lot of activity and research going on in that area. There’s also continued research into hand hygiene and the human-factors engineering that help us design systems in which the right care is forced, if you will, instead of relying on memory and vigilance. Human-factors engineering will help us better understand why even though health care workers know it’s the right thing to wash their hands, some don’t. And even though health care workers know they should be vaccinated against influenza, some aren’t. These [answers] will help us move along evidence-based practices faster.
Q Some of the things you just mentioned, including human behavior, can help reduce infections even in hospitals that may not have a lot to spend for new technology.
A Absolutely. Hand hygiene is probably one of the most low-tech solutions that hospitals can use to decrease infections. And we know from the literature that hand-hygiene compliance is 40 percent to 60 percent in most facilities. We have to keep working until it is 100 percent. And developing new technologies such as the waterless hand-hygiene agents—the alcohol-based hand rubs—have really helped us by making it a lot easier for people to do the right thing. Those are the kinds of solutions that we need to keep investigating.
Q Do you see anything on the horizon that might affect the prevailing recommendations on best practices?
A There’s so much research going on right now, including the National Surgical Quality Improvement Program for surgical-site infections from the American College of Surgeons. As the data is collected, it will be analyzed to see if there are other things that we could and should be doing besides the traditional [practices such as] hand hygiene. There’s a tremendous amount of research going on in surgical-site infection prevention and ventilator-associated pneumonia prevention. Hopefully, technology and research into human behavior will continue to help drive down hospital-associated infection rates.
Q Do you anticipate the government coming out with other rulings that might be designed to either provide incentives or financial penalties around the HAI issue?
A CMS has pilot projects on physician-specific pay for performance because we need to find creative ways to get hospitals and physicians to work together more effectively and work toward the same goals. Some of the CMS demonstration projects that, for example, allow hospitals to incent physicians for helping to improve the quality of care delivered will be helpful.
Q Do you anticipate seeing more attention on the part of hospital administrators for infection control procedures as a result of the new CMS ruling?
A I think even more [influential] than the CMS ruling per se is just the general heightened awareness of consumers. That has elevated attention around infection control because, frankly, in the distant past, infection control had been seen by many CEOs as a cost center.
But I think with all the attention there is on patient safety and health care-associated infections, [CEO attitudes are] changing. And administrators are seeing health care epidemiology and infection control as kind of the pioneers of patient safety in terms of proactively trying to decrease adverse events in hospitals.
Q Is there a commensurate impetus to increase budgets and provide more resources for infection control as a result?
A I can only speak to facilities where I work, but I think every hospital has to set priorities. Every hospital has a different infection rate, and every hospital has its own budgetary concerns and issues.
What we have to focus on in terms of the profession of infection control and epidemiology is making sure that we do an adequate risk assessment in our own facility so we can prioritize our efforts to have the biggest impact on reducing infections. We have to invest in infection control departments and know where the issues are in our facilities through a thorough infection control annual risk assessment.
Q How much does it cost a hospital if a hospital-associated infection arises?
A Research about this is available from the CDC, the Society for Healthcare Epidemiology of America, and APIC. Resources are available on their Web pages (www.cdc.gov, www.shea-online.org and www.apic.org, respectively), and one focus is on making the business case for infection control. But more than that, most of us in this society [APIC] have spent our whole careers on just this issue. So we are glad that the light has shone on reducing infections in all patients all the time.
It certainly is not a new field. But we have new techniques and new political will from a broad perspective to make sure that these evidence-based practices are fully implemented. I think some of the attention from CMS and others, including the payers and consumers, is helping to bring to light the challenges that we’ve faced in infection control for a number of years.
Q Has anyone tried to estimate what the bill is going to be as a result of the CMS ruling, given that hospitals can’t get the infection rates down to zero? How much of a financial burden is that going to place on hospitals each year?
A It’s difficult to predict that right now because of a lot of factors. The CMS is moving from the traditional DRG [diagnosis-related group] system to MSDRGs [medical severity diagnosis-related group]. So we don’t know what effect that is going to have. The whole DRG system essentially is being redone.
Q Can you help us understand what this means for hospitals in the HAI context?
A A new system will be rolled out in January with the MSDRGs and the “present on admission” (POA) code. The DRGs will be divided into three categories, with low severity, mid-range and high severity for reimbursement. Plus, because of the POA codes, CMS will be able to parse out those things that developed in the hospital versus the things the patient had before coming into the hospital.
Q So are financial costs up in the air until this gets put into place?
A Right, because CMS’ decision takes effect in October 2008 for fiscal year 2009. So, we have to implement the MSDRGs and the POA code in the meantime.
Q It sounds as though each hospital is going to have to work through these changes before really understanding what the specific impact will be.
A Right. And the states that have tried to implement the POA forms found that it took about two years to be able to code these things. It’s such a big change. I don’t think the impact will be felt immediately because we have less than a year to implement the POA codes, and it’s going to take some time to train all the coders.
All the physicians have to be trained in terms of documentation to be able to call something POA versus something that develops in the hospital. Hospitals really have their work cut out for them just to implement the new POA codes and the MSDRGs. Also, CMS is not changing outlier payments. There are certain patients who, because of their underlying conditions, have many complications. They are way outside the length-of-stay average for a DRG, so hospitals get higher reimbursements for those cases. Also, we don’t know how many potential HAIs exist because they happen in very sick people; and this situation may kick a patient into outlier status. Patients stay in the hospital longer because of all their complications, so an HAI may have absolutely no effect. There are so many complexities, it’s really difficult to predict what the effect is going to be. But I think from a professional society standpoint, our goal is to reduce as low as possible—if not eliminate—infections.
This article first appeared in the November 2007 issue of Materials Management in Health Care.
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