Hospital-Acquired Infections and CMS Reimbursement: Implications for Hospitals
HealthOctober 23, 2018

Hospital-acquired infections and CMS reimbursement: Implications for hospitals

The Centers for Disease Control and Prevention (CDC) estimates that, on any one day, as many as one in 25 hospital patients suffer from a hospital-acquired infection (HAI). While the latest data shows a significant decrease in infection rates of both MRSA and C. diff in acute care settings and inpatient rehabilitation facilities — 7% and 8%, respectively — HAIs continue to trouble patients and providers alike.

Both MRSA and C. diff are of particular concern because of their antibiotic-resistant nature. Complications from both bacteria can be severe and include secondary infections, sepsis, and even death. And while these concerns are of paramount importance, there’s another aspect of HAIs that many often overlook. Specifically, the relationship between hospital and provider reimbursement and HAI rates.

The hospital-acquired condition (HAC) reduction program

In an effort to curb MRSA and C. diff infection rates nationwide, the Centers for Medicare & Medicaid Services (CMS) implemented the HAC Reduction Program. Beginning in 2015, payments to hospitals would be directly affected their HAC scores, garnered, in part, by HAI rates.

Generally, hospitals are scored according to patient outcome measures. These measures include specific patient safety indicators (PSIs) divided into two domains. Each PSI is scored and averaged to arrive at a composite score for each facility.

Domain 1

The first domain, which has remained largely unchanged, scores hospitals according to reported rates of:

  • Accidental punctures or lacerations
  • Falls resulting in hip fractures
  • Iatrogenic pneumothorax
  • Post-operative complications, including:
    • Acute kidney injury requiring dialysis
    • Pulmonary embolism and DVTs
    • Respiratory failure
    • Sepsis
    • Wound dehiscence
  • Pressure ulcers

Domain 2

At first, the second domain focused on standardized infection ratios of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and surgical site infections (SSIs). In 2017, MRSA and C. diff infection rates were added to domain 2.

While only 15% of a hospital’s total HAC Reduction Program score is attributable to their scores in domain 1, a full 85% of a facility’s score comes from domain 2.

The impact on hospitals

The CMS’s non-payment policy for HACs, including MRSA and C. diff infections, has already saved Medicare almost $350 million each year. Total Medicare payments to facilities with HAC Reduction Program scores greater than the 75th percentile (i.e. the worst scoring facilities) are reduced by 1%. Each payment is adjusted when CMS receives and pays hospital claims.

That figure represents money that isn’t going back into patient care, and treating both MRSA and C. diff is expensive. A recent study examining treatment costs for found that it takes about $38,500 per patient to treat drug-resistant staph infections (MRSA-related pneumonia). Additionally, it costs almost $24,205 to treat each person with C. diff. If the C. diff infection recurs, an additional $10,580 in healthcare costs is expected.

Hospitals respond with quality improvement efforts

As a result of the HAC Reduction Program and the monetary penalization for low-performing facilities, many hospitals have implemented quality improvement (QI) initiatives aimed at reducing infection rates and improving patient outcomes. In many instances, hospitals allocate more resources toward preventing both MRSA and C. diff infections. And while several studies indicate that rates of hospital-acquired conditions have fallen since the start of the HAC Reduction Program, other suggest that MRSA and C. diff infection rates can’t be directly correlated to the program’s non-payment policy or any QI initiatives.

There is also growing interest in patient’s perceptions of care and a hospital’s HAC Reduction Program score. Facility and provider reimbursement are increasingly tied to patient satisfaction, but it is unclear how these scores are influenced by the HAC Reduction Program. Current research indicates that hospitals providing a higher quality of care (represented by a lower HAC Reduction Program score) generally had better overall patient satisfaction.

But other studies suggest no relationship or inverse relationships between patient satisfaction and PSIs. Clearly, more research is necessary to determine just how much of an impact a hospital’s HAC Reduction Program score has on the overall quality of care they provide.

New! Quality and safety navigator

To help organizations continue driving towards improved care quality and increased reimbursements, we’ve recently updated Lippincott® Advisor with a new program set called Quality and Safety Navigator.

This new content includes topic overviews and improvement planning strategies for 50 targeted quality measures such as:

  • C. Diff
  • Hospital Acquired Pneumonia
  • MRSA
  • Patient Satisfaction
  • Pressure Injury
  • Sepsis
  • Surgical Site Infection

As one of the four tools comprising the Lippincott® Solutions suite, Lippincott Advisor is the best in class resource for instant, point-of-care clinical decision support with over 17,000 evidence-based content entries and patient teaching handouts.

Click HERE to learn more about how Lippincott Advisor can enable your organization to make more informed decisions at the bedside and reduce your risk of errors.

Explore related topics
Lippincott® Solutions
Our best-in-class suite of evidence-based, institutional software can help you to balance clinical and business needs by streamlining workflow, standardizing care, and improving reimbursable patient outcomes.
Back To Top