Becker's Clinical Quality & Infection Control

14 Sign up for the Free Becker's Clinical Quality & Infection Control E-Weekly at www.beckersasc.com/clinicalquality. The high price of inaction One reason for that failure may have been an unintended consequence of government payment policies, which initially focused attention on a few HAIs. Since 2008, Medicare has refused to pay the added cost of treating catheter-associated urinary tract infections and central line-related bloodstream infections, a policy since extended to surgical site infections following coronary artery bypass grafts, bariatric surgeries and orthopedic procedures. A Harvard study published in the New England Journal of Medicine in October 2012 found no evidence that the Medicare non-payment policy had any measurable effect on infection rates in the U.S. One issue blunting the impact of the law is that hospitals can continue to bill for not only the diagnosis present on admission, but also comorbidities for infected patients. In fact, CMS has admitted that nationally only about $50 million to $60 million has been withheld each year from hospital reimbursements. "If you think about that amount of money spread across 5,000 or 6,000 facilities, hospitals haven't had a lot of skin in this game, but the no-pay rule did get people's attention because it was the first time there were any payment ramifications related to quality," says Ed Septimus, MD, a professor of internal medicine at Texas A&M Health Science Center in Houston, who previously ran infectious disease programs at Memorial Hermann Healthcare System. Newer payment penalties, however, are rapidly changing the picture, making a focus on a few infections all but impossible for institutions seeking to retain full payment under Medicare. The Patient Protection and Affordable Care Act introduced the Hospital Inpatient Value-Based Purchasing Program, the Readmissions Reduction Program and a new withholding program for adverse events. The law also broadened the Inpatient Hospital Quality Reporting Program, with more data required to be reported through the National Healthcare Safety Network.   Value-Based Purchasing began in earnest in October 2012 with a 1 percent withhold of baseline DRG payments (the potential penalty will rise to 2 percent by 2016). To earn back a portion or all of the withhold, hospitals must perform well on a combined score based on clinical quality indicators and patient satisfaction measures. For fiscal year 2013, 70 percent of the score is composed of clinical process measures, including several related to infections. In all, for fiscal year 2013 Medicare is rewarding 1,557 hospitals with more money and reducing payments to 1,427 others, according to CMS data. The VBP program will be even more painful for hospitals when "double jeopardy" kicks in. Beginning in October 2014, another 1 percent penalty on all Medicare payment will be assessed for hospitals in the bottom quartile of all healthcare-associated conditions — the so-called "never events" that include HAIs — doubling down on the nonpayment rule. "Once you are in it, you might not ever get out of that quartile," Mr. Septimus notes. All hospitals will be racing to improve, using many of the same best practices, such as the Keystone initiative in Michigan, which dramatically reduced central line-related infections in that state's hospitals.  Readmissions Under a policy that began to take effect Oct. 1, 2012, hospitals with high rates of 30-day readmissions are subject to a payment penalty, withthose with excess readmissions are penalized 1 percent of baseline MS-DRG payment. That maximum penalty will rise over two years to 3 percent. In the first year of the program, 2,217 hospitals, or 63.4 percent received penalties for having too many readmissions, and 307 hospitals received the maximum 1 percent penalty. Post-discharge infections are one of the leading causes of readmissions, especially for surgical patients, studies show. Hospital patients with a positive clinical culture for MRSA, vancomycinresistant enterococci or Clostridium difficile are 40 percent likelier to be readmitted within a year than other patients, said a study in the June 2012 issue of Infection Control and Hospital Epidemiology. "By 2014 to 2015 we will really see for the first time a real change in reimbursement based on hospital performance on these measures," Mr. Septimus says. "A few percentage points of revenue adds up to some real financial pressure if you do not perform to a certain level for these reportable conditions." Payment reform is hardly limited to Medicare. Starting July 1, 2012, the PPACA prohibited federal Medicaid matching funds to states for payments attributed to care provided for the same conditions as the Medicare nonpayment rule. Reporting concerns Since January 2011, hospitals participating in the Hospital Inpatient Quality Reporting Program have had to report central line-related infections to the National Healthcare Safety Network or risk loss of 2 percent of baseline Medicare payment. In 2012, the program expanded to cover urinary tract infections and infections from inpatient colon and abdominal hysterectomy surgeries. Blood Borne Pathogens 1-800-932-7472 www.imageerst.com Compliant Beginning in January 2013 inpatient acute-care facilities must report MRSA and C. difficile infections to NHSN.

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