'Passive payer' no more: New CMS requirements hitting hospital budgets
'Sunlight is a great disinfectant.'
By Gary Evans, Executive Editor
Special Report: Affordable Care Act changes infection prevention
Empowered by the Affordable Care Act, federal agencies are enacting a series of programs and initiatives to prevent health care associated infections. With the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention collaborating on many of the efforts, infection control is now irrevocably linked to the era of pay for performance.
A broad array of new federal regulations on health care associated infections (HAIs) continue to come on line in 2014 and beyond, tying infection prevention more directly to the hospital bottom line than at any time in the field's history.
"Every one of our contracts now include a mandate for a percent reduction in infection rates in order to get the best payment," says Denise Murphy, RN, MPH, CIC, Vice President of Quality and Patient Safety at Main Line Health in suburban Philadelphia. "So aside from the government piece of it with CMS, you've got the private insurers now saying, 'If you want to make more money, reduce your infection rates, reduce your readmission rates, reduce your mortality rates.'"
Testifying at a recent Congressional Hearing on HAIs, a top official with the Centers for Medicare and Medicaid Services outlined a number of federal initiatives that are creating strong financial incentives for hospitals to prevent infections and medical errors.
"In the past, hospitals had little financial incentive to improve the quality of their care because Medicare and other purchasers paid hospitals for treating infections or errors even when they could have been prevented," said Patrick Conway, MD, director of the Center for Clinical Standards and Quality at the CMS. "Now, Medicare, state Medicaid programs, and many private sector health plans and purchasers, are moving rapidly to change payment systems to reward better outcomes instead of volume of services. CMS is working to transform from a passive payer to an active purchaser of higher-value health care services."
Some of the provisions are part of the Affordable Care Act (ACA), with the CMS requiring many of its measures to be reported to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) and ultimately publicly posted on the CMS Hospital Compare site. (See chart p. 4; stories, p. 6; p. 9.)
"Sunlight is a great disinfectant, and public reporting of hospital infections is the sunlight the public has asked for and deserves when it comes to their health and safety," CDC Director Tom Frieden, MD, MPH, said when the most recent CDC data were posted on CMS Hospital Compare. With both CDC and CMS firmly on board, the once controversial prospect of state and federal HAI reporting and payment regulations is an expanding reality.
Moving from process to outcomes
The next few years will be particularly telling as CMS Value Based Purchasing (VBP) shifts from an initial focus on process measures to assess a greater proportion of hospital outcomes. In FY 2015 those outcomes will include central line associated bloodstream infections (CLABSIs), which will be followed by catheter-associated urinary tract infections (CAUTIs). In addition to VBP, provisions under the Hospital Readmission Reduction Program (HRRP) – also mandated under the ACA – are beginning to take effect. Though separate programs, VBP and HHRP together can put at risk up to 5% of Medicare payments by FY 2017, Murphy explained.
"[That projection] was put together by our quality fiscal analysts and it tells you where value based purchasing is going," she tells Hospital Infection Control & Prevention. "Right now we are looking more at process measures. As you start to move to 2014 and 2015 this equation is totally flipping to outcomes. Device-related infections are part of the outcome equation and we are going to see that change. It may not have hit the pocket book enough yet, but by 2015, when the VBP program is fully up and going, we are going to start to feel some heavy penalties."
The impact on the individual IP facing increasing data collection and reporting demands remains a concern. Without increased program support, it is not hard to imagine that infection control initiatives in other areas may be at risk as the focus shifts to the CMS targets.
"Although [VHP] has created a burden in one respect it has not provided resources in another respect," says Patti Grant, RN, BSN, MS, CIC, president of the Association for Professionals in Infection Control and Epidemiology (APIC). "But it can't all happen at once, only time will tell if it is going to balance itself out. You have to ask yourself are we getting ready to come full circle with collecting too much data? I do worry about that on a personal level, not as APIC president, but as an individual IP. I spend 70 to 80 percent of my time in data collection and there are some days when I wonder when I am going to get around to teaching again."
Reporting will lead to a greater good
Patient safety advocates that have been pushing for state and federal HAI reporting requirements say increasing transparency and accountability will yield a greater good.
"It has been a game changer," says Lisa McGiffert, director of the Safe Patient Project at the Consumers Union, publishers of Consumer Reports. "I believe that three things created a convergence of change around infections. One was mandated public reporting that consumers pushed for, another one was payment policies, and the third is programs that were funded to help hospitals learn how to prevent infections. Most people in the public arena believe that is a very basic thing that hospitals should know, but they don't always know."
Such programs include the Institute for Healthcare Improvement's 100,000 Lives Campaign and the highly publicized "checklist" CLABSI reduction program in initiatives like the Keystone Project in Michigan.
"On the payment side it started with the hospital acquired conditions back in 2008 that Medicare put out there, saying 'We are not going to pay for these infections anymore,'" she says. "Then there was the payment for reporting — that's how they started the federal infection reporting to bring in the rest of the states that didn't have mandates. So the next step will be taking away money from the hospitals that have the highest rates."
Some 30 states have enacted laws to report HAIs, many of them issuing periodic reports that are available at the Consumer Union's website. (http://safepatientproject.org/tags/state-disclosure-reports)
"The bottom line is the public wants to know — they really feel like hospitals should report infections," McGiffert says. "I think we are moving into a stage of escalating reporting all over the country and then also pushing to better translate that information so the public can actually use it."
Though some have questioned the ultimate patient safety impact of HAI reporting and threats to reimbursement, McGiffert points to the sudden move to adopt systems to remove catheters and prevent UTIs after the CMS cut payments.
"With UTIs, now more hospitals have [prevention] systems because they have to be reported and they are getting financial disincentives if they don't get those down," she says. "That increased a lot of activity to not use as many catheters, get them out more quickly — those kinds of pretty simple things that were not automatically happening."
Where is the outrage?
In addition to pushing for transparency and accountability on HAIs, consumer and patient safety advocates are a powerful public voice in part because they have not lost their initial outrage at finding out that 100,000 patients a year die of infections.
"It has always been curious to us and devastating to the people who experience these infections that there isn't somebody at the CDC who is pounding their fist and saying, 'This has to stop!' That hospitals aren't outraged that so many people are getting hurt," she says. "It's very difficult to understand. I think the culture has changed a lot over the last 10 years, but there still is a sense of inevitability for a lot of these [HAIs]. There is certainly more awareness and lives saved every day, but we don't really have a national system to support the work that needs to be done. Hospitals need to invest more money in infection prevention than they are today. Some of them are, but across the board they are not. That is a problem. It should be as fundamental as funding for beds and oxygen tanks. The infection preventionist is fundamental to health care."
Despite all the demands and elevated expectations, preventing HAIs is not as simple as telling all health care workers to wash their hands. Health care delivery is a complex proposition with a lot of moving parts and unforgiving moments. The days of inevitable infections are long gone and striving for zero is the goal, but there is an outer limit to the efforts of even the best IP.
"We know that everything is not preventable," says Murphy. "Some bad outcomes are related to host factors. Clinicians can do everything right and still the patient could get an infection. Someone can still die of sepsis even if the team pulled the trigger for rapid identification, rapid implementation of important protocols, checking of every single box properly and in a timely fashion."
That said, Murphy says it's counterproductive to get into academic arguments about what percentage of HAIs can be prevented.
"There is no nationally accepted definition of 'preventable,' but we know that we can prevent most HAIs," she says. "For those that we can prevent, let's stop arguing whether it is 70% preventable and 30% that is not? Is it 80%-20%? Is it 90%-10%? Let's get off of that and focus on what we know — most HAIs are preventable."
Clinical and 'people bundles'
A former hospital infection preventionist who has moved up to the C-suite, Murphy keeps her CIC certification in infection control up to date and provides a unique perspective on a problem she is passionate about: HAI prevention. One of the first IPs to begin making the "business case" for infection control, Murphy knows both the value of prevention and the many competing demands on hospital budgets.
"I have lived the role of the IP at the bedside, watching how hard it is for people to comply with all of our prevention efforts," she says. "They are not complying because they are bad or they don't want to do good infection prevention. When you stand and watch an ICU nurse, for example, you see all of the possible opportunities there are for her or him to wash their hands, or scrub a hub, or to keep the urinary catheter bag at the level of the bladder. You may ask, 'How do they even do all of this?'" We are so good at standard setting but poor at following through with implementation."
The more elusive challenges to compliance must be identified and addressed, she notes.
"We need to understand why people can't possibly comply with all the prevention measures that we throw at them, Murphy says. "You can't have infection prevention alone without performance improvement and process engineering, human factors — all of the things that help people comply. We can't just be penalizing the frontline staff for not complying with our CLABSI or CAUTI checklists. We've got to figure out why they can't comply. 'Why can't you comply?' is a different question than 'Why aren't you complying?'"
Murphy advocates both the various clinical bundles and "people bundles" that combine to form an institution's reliable culture of safety.
"When I say 'people bundle', I mean that we start with setting clear expectations for people in every role – and they are going to be different from the hospital board down to the people who care for patients every day – setting clear behavioral expectations relative to a team member's role in patient safety and infection prevention," she said. "That's a critical job of leaders to set clear expectations. Next provide people with the education, tools and training to do the job you have asked them to do. Finally, build and sustain accountability."
A key to improving compliance is giving staff the ability to speak up, more in a sense of esprit de corps than scolding tones.
"You have to have conversations with people, with a unit staff, saying, 'In our unit we will have each other's backs and we will not allow risky behaviors,'" she emphasizes. "You need to know if you go into an isolation room without isolation garb, start a central line without the appropriate draping and gown — we will stop the line. That's having your back and your patient's back. Are you in?"
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