Hospitals Face Medicare Funding Reductions Due to High Infection Rates

Under a program established through the Affordable Care Act, 769 US hospitals will receive Medicare reimbursement reductions due to the high rates of hospital-acquired infections.

In a recent announcement from the Centers for Medicare and Medicaid Services (CMS), hospitals around the United States will be facing a financial penalty from the agency after failing to bring down their rates of hospital-acquired infections.

In a 2014 study published in the New England Journal of Medicine, researchers found that nearly 722,000 healthcare-associated infections occurred in US hospitals in 2011, and that an estimated 75,000 of those patients died while hospitalized. The infections included pneumonia, gastrointestinal illnesses, urinary tract infections, primary bloodstream infections, surgical site infections, and others acquired by patients during hospital stays. More recently, a Consumer Reports study gave low marks to a number of US hospitals after they reported rates of Clostridium difficile infections higher than the national benchmark. Despite these figures, a recent report from the US Department of Health and Human Services announced a 21% decline in hospital-acquired infections from 2010 to 2015.

Hospital infections continue to persist and affect the health of patients; however, and in response the Hospital-Acquired Condition (HAC) Reduction Program became effective in 2015 through Section 3008 of the Patient Protection and Affordable Care Act (ACA). Under the program, US hospitals are subject to penalties in the form of Medicare reimbursement reductions based on how they score on rates of hospital-acquired infections. The scores are based on six quality measures from the Agency for Healthcare Research and Quality’s Patient Safety Indicators 90 Composite, and the Centers for Disease Control and Prevention’s National Healthcare Safety Network for central line-associated bloodstream infections, catheter-associated urinary tract infections, and surgical site infections, methicillin-resistant Staphylococcus aureus bacteremia, and Clostridium difficile infection measures. Hospitals with the lowest ranking under these measures—those with a total HAC Score above the 75th percentile–are subject to having their Medicare payments reduced by 1%.

The recent announcement from CMS looked at rankings for more than 3,300 US hospitals around the country, with 769 hospitals receiving federal reimbursement reductions due to high rates of patient infections in their facilities. As of yet, CMS officials have not released estimates on the total amount of funding reduced by the recent penalizations. Under the recent ratings, eight Utah hospitals face penalties, including the Intermountain Medical Center, which received $966.3 million in patient service revenue from Medicare payments in 2015. In Texas, a total of 61 hospitals are also losing Medicare funding for 2017 after receiving low scores on their number of hospital-acquired infections.

The HAC program is part of an effort to impact the quality of care in the US healthcare system and reduce the number of infections acquired by patients during hospitalization. In a 2013 study in the CMS publication Medicare & Medicaid Research Review, researchers compared the rate of some hospital-acquired infections in relation to Medicare penalties implemented under previous measures and found that the rate of hospital-acquired infections went down in response to those policies. In Virginia, where the Virginia Commonwealth University Health System was one of 19 hospitals affected by the recent CMS announcement, VCU officials noted that the agency’s ranking does not reflect progress made within their system of healthcare facilities.

“In Federal Fiscal Year 2016, 62% of the nation’s academic medical centers will face penalties for higher HAC scores,” said a recent VCU statement released to Contagion. “The data used to determine the total HAC score is not risk-adjusted for hospitals such as VCU Medical Center, which is the commonwealth’s largest safety-net provider. As an academic medical center, and the region’s only Level I trauma center, VCU Medical Center provides a significantly higher level of care to a disproportionate share of patients who are among the sickest and most complex to treat. VCU Health has an evidence-based infection prevention program that tracks process and outcome measures. We are relentlessly pursuing high reliability in all aspects of the infection prevention program. As such, we are expecting to have fewer infections in 2016 when compared to 2015, consistent with our trend of decreasing hospital-acquired infections over the past 14 years.”