Requiring reporting of health care-associated infections for reimbursement is a lot messier than one might think.
Reimbursement from the US Centers for Medicaid and Medicare (CMS) is a critical component of a hospital’s stability and a large portion of the reimbursement is linked with hospital-acquired conditions (HACs). These HACs include hospital-associated infections (HAIs) like catheter-associated urinary tract infections, surgical site infections for certain surgeries, and central line-associated bloodstream infections. The 2008 Inpatient Prospective Payment System (IPPS) Final Rule included 10 categories of HACs that were tied to CMS payment, meaning that reimbursement was linked with quality of care. Simply put, this was a way for CMS to force hospitals to cut down on HACs and improve quality of care and patient safety.
Despite data from the US Centers for Disease Control and Prevention (CDC) indicating that rates of HAIs in the United States have been on the decline, with a 50% decrease in central-line associated bloodstream infections, and a 17% reduction in surgical site infections between 2008 and 2014, the fact of the matter is that the United States has an HAI problem. A total of 721,800 cases of HAIs were reported in 2011, alone, and so perhaps it is not surprising that regulatory actions were taken via CMS to incentivize hospitals to make efforts to reduce them. Still, the burden of infection prevention reporting for CMS reimbursement remains substantial, and there are considerable concerns regarding the accuracy of reporting and how medical providers are handling culturing to avoid identifying HAIs.
In response to this, CMS has issued a proposed rule for the fiscal year 2019 IPPS that would remove HAIs from 1 of the 3 programs that are tied to reimbursement (through either HAI rates or reporting requirements). Currently, HAI reporting measures fall into 3 programs: Hospital Inpatient Quality Reporting Program, Hospital Value-Based Purchasing Program (VBP), and the HAC Reduction Program (HACRP). In this proposed rule, HAIs would be pulled from the Hospital Inpatient Quality Reporting (IQR) and Hospital Value-Based Purchasing programs and would solely fall in the HAC Reduction Program.
One might think this would be a welcomed approach for infection preventionists as it would lead to less reporting requirements, right? Wrong.
This action is wholly unsupported by infection preventionists, and in fact, the Association for Infection Professionals in Infection Control and Epidemiology (APIC) submitted official comments asking for amendments to the rule.
APIC’s comments highlight some hard truths for infection control programs within the United States, such as the fact that many quality reporting efforts are duplicative and time-consuming, leaving less time for the education and rounding that is critical to reducing HAIs. In the comments, facilitated by 2018 APIC president Janet Haas, PhD, RN, CIC, FSHEA, FAPIC, the society notes that maintaining the penalties in only 1 program would not only hinder accurate measurement on a facility’s performance, but could also punish hospitals that treat a majority of patients who are at higher risk of health care-associated infections.
“[B]y retaining the measures only in the HACRP, penalties would be based only on each facility’s performance compared to other facilities, so do not fulfill the Meaningful Measure objective of significant opportunity for improvement,” the statement reads. “This might result in continually penalizing hospitals that serve predominantly high-risk patients even if a hospital’s individual performance improves from year to year. The Hospital VBP Program, by comparison, provides incentives for each facility’s performance improvement as well as penalties for poor performance. Therefore, APIC recommends that the NHSN HAI measures be retained in the VBP program and removed from the HAC Reduction Program.”
Moreover, these changes would not change much in terms of burden and workload for infection preventionists. The same types of reporting are required, and high rates of HAIs are still linked with financial penalties. In fact, there is concern that these proposed changes could give the impression that less work will occur, leading to a reduction in staffing for infection control programs, which has, ironically, already been cited as the cause of high HAI rates and even referred to by union leaders and workers as proof of staffing needs.
APIC’s comments were sent to CMS in late June and only time will tell if the agency will change direction on the proposed requirements for HAI reporting. What we do know is that this struggle continues to highlight the complexities and challenges we face every day in the changing world of infection control. Sadly, oftentimes we see that efforts to hold hospitals accountable for HAIs by tying them to financial penalties mean that there is more administrative focus on efforts to prevent them, and little else. And, this administrative burden of surveillance and reporting falls on an institution’s infection prevention program, taking team members away from efforts such as reducing HAIs not tied to reimbursement, tackling antimicrobial resistance, ensuring emergency preparedness, sterilization and disinfection, environmental rounding, isolation and hand hygiene compliance, etc. Tying HAIs to financial penalties is a double-edged sword, and despite our best efforts to reduce them, the complex world of health care doesn’t allow for easy fixes.