The challenge of reducing C. diff infections in a health care system driven by ‘perverse incentives’

January 12th, 2015

At a recent meeting on that problematic nasty pathogen Clostridium difficile, the dramatic reductions of C. diff infections by hospitals in the United Kingdom cast something of a pall over the proceedings. While U.S. epidemiologists pointed to slides to take solace in incremental reductions and the faint hope of plateaus, UK C. diff infection rates crashed down on charts like the stock market on a black October day.

Many noted that you can’t really compare such distinctly different health care systems, though the tone was set early when a speaker said the comparative data between countries was nothing less than an “indictment” of the very people in the room.

Perhaps feeling more indicted than others as the leading C. diff expert at the Centers for Disease Control and Prevention, L. Clifford McDonald, MD, FACP, gave a surprisingly frank assessment of what it is like to try to reduce health care infections (HAIs) in a fragmented U.S. health system driven by “perverse incentives.”

“We hear or read all kinds of literature about the cost of an HAI or the cost of an adverse patient event, but what you don’t read very much about – because there is very little data on it – is what are a hospital’s margins on an adverse event,” he said. “Hospital margins are not at all clear. Most of their costs are what is known as ‘fixed costs’ — you have all of these costs that go on. It is not always clear that hospitals lose money on HAIs. It’s just a fact.”

While essentially suggesting that HAIs are factored in as part of the overall cost of doing business, McDonald added that hospitals may also seek out diagnosis-related groups (DRGs) that reimburse at higher levels — typically for care delivered in intensive care units.

“Sometimes they do [lose money on HAIs] because they are in a market where they could get a much higher reimbursing DRG,” he added. “This is where you will find sometimes that CFOs and CEOs are much more interested in the capacity of your ICU than anything else because you can get another higher-reimbursing DRG into an ICU after a CABG or something like that. This all has to do with why we have surgeons who don’t wash their hands and do whatever else they want, and no one from the central office ever jumps on them. Why? Because they bring in all these highly reimbursed DRGs that have a high positive margin. This is the underbelly — what we really don’t want to talk about. But this is the reality of what is going on in health care. It is a volume driven system. It is not a quality driven system. It is not an outcomes driven system.”

For more on this story see the April issue of Hospital Infection Control & Prevention