EDITORIAL
Not Paying for Catheter-associated Urinary Tract Infections More Difficult Than it Seems? Robin E. Clark, PhD and Karen M. Clements, ScD
P
olicy interventions that attempt to influence patient care can be hard to implement and their desired outcomes can be slow to achieve. The efforts of the Centers for Medicare and Medicaid Services (CMS) to reduce preventable infections by withholding payment for additional expenses related to catheter-associated urinary tract infections (CAUTI) illustrate this challenge clearly. In October of 2008, CMS began a policy of refusing to pay hospitals for additional costs related to CAUTI and 7 other potentially preventable events or conditions. The list was expanded to include 3 new conditions in 2013.1 CAUTIs represent more than one third of all hospital-acquired infections and are costly to treat.2–4 Medicare patients appear to have much higher rates of CAUTIs compared with other groups.5 Initial reactions to the rule varied widely. Some observers predicted large reductions in hospital revenue6 and others suggested that hospitals might compensate by charging for more complicated conditions or comorbidities and by relying on outlier payments to cover additional time spent in the hospital to treat the infection.7,8 CMS predicted savings from the new rule of $21 million–$22 million per year between 2010 and 2014 from reduction in reimbursement for the 8 original hospital-acquired conditions combined.9 Follow-up studies using hospital discharge reports from a single state, the National Hospital Discharge Survey, or the National Healthcare Safety Network (NHSN), a reporting system maintained by the Centers for Disease Control, show that CAUTIs have not declined significantly since the policy was implemented.10–12 The study by [authors] suggests at least 2 reasons why the nonpayment initiative has not been more effective in reducing CAUTIs. The first problem was a flawed monitoring system. Any new policy must have a way to accurately track the behaviors it seeks to influence. As [authors] and others describe, CMS originally relied on International Classification of Diseases-9th revision (ICD-9) codes on Medicare claims to identify CAUTI; this method was ineffective because the codes required to identify CAUTI events were often not reported on claims. A further complication was introduced when CMS asked providers to report new “present on admission” codes after the 2008 implementation date. Any change that requires providers to record and report new data may take time to implement. Further, because claims are primarily used for paying providers, there was a weak incentive to record an unreimbursable condition. Moreover, earlier studies showed that catheter placement is not always recorded accurately in physician notes in medical records, which are the source of billing codes.13 To address the issue of underreporting in their analysis, [authors] used the NHSN to identify CAUTIs, then linked infection reports to Medicare claims to compare payments for patients with a CAUTI to a similar group without evidence of a urinary tract infection. Because the NHSN was specifically designed to monitor health care–associated infections, it was less likely to suffer from the type of underreporting observed in claims.
From the Center for Health Policy and Research, University of Massachusetts Medical School, Shrewsbury, MA. R.E.C. is a co-principal investigator for a grant application that is currently under review by the Centers for Medicare and Medicaid Services. K.C. declares no conflict of interest. Reprints: Robin E. Clark, PhD, Center for Health Policy and Research, University of Massachusetts Medical School, 333 South Street, Shrewsbury, MA 01545. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5206-0479
Medical Care
Volume 52, Number 6, June 2014
www.lww-medicalcare.com |
479
Editorial
The results of the analysis by [authors] suggest a second reason why the nonpayment rule has had little impact. Far from receiving no payment for CAUTIs, the study shows that hospitals have continued to receive substantially higher payments for them after the initiation of the 2008 policy. It is not clear how these payments compare with the actual cost to hospitals of delivering care. Possibly the higher payments did not cover the full costs of treating CAUTI. Nevertheless, the significantly higher payments reduced the financial consequences of CAUTI to hospitals and thus weakened the incentive to change their current practices. The mechanisms driving increased Medicare payments for CAUTI patients were predicted by some early prognosticators. Compared with their claims for similar patients without infections acquired during their stay, hospitals assigned more complex Diagnostic Related Group codes (DRGs), identified more co-occurring conditions, and billed more outlier payments to cover the significantly longer stays required to treat CAUTI patients. These are most likely real costs incurred by hospitals. [Authors] clearly show longer lengths of stay and that the patients involved have a number of co-occurring conditions or comorbidities that may or may not be related to CAUTIs but which raise the cost of care, perhaps justifying a shift to a higher weighted DRG. Given the challenges of identifying CAUTIs and of distinguishing between allowable expenses and those that are not reimbursable under the nonpayment rule, how might CMS improve monitoring and enforcement? A potential solution to the case identification problem is suggested by the methods used by [authors]. Indeed, in 2012, CMS began requiring all hospitals with intensive care units (ICUs), where the larger payment differentials are found, to report infections among ICU patients through the NHSN.14 By relying on NHSN reports rather than Medicare claims for case identification, CMS can identify cases with greater accuracy. [Authors] found higher odds of death among patients admitted to the ICU with a CAUTI (OR = 1.37). Although mortality was not elevated among cases from Pennsylvania, the only state in the sample where hospitals were required to report infections to NHSN, additional evidence supports the finding of increased mortality among CAUTI patients.3 A focus on patients in ICUs is likely to produce the greatest benefit. CMS will add a requirement to report all cases in adult and pediatric medical, surgical, and medical/surgical wards in 2015, which will allow identification of virtually all CAUTIs in acute care settings.14 CMS is still challenged with deciding how to pay hospitals for patients with complex conditions when there is a CAUTI. The Centers could deny outlier payments for stays that exceed the expected length when a CAUTI is identified. Cases in which the reasons for a longer stay were plausibly unrelated to a CAUTI might be subjected to appeal or a special review. The problem of how to determine which, if any, co-occurring conditions were likely related to the CAUTI remains a challenge. Improved reporting and monitoring of CAUTIs will increase transparency and apply greater pressure on hospitals to reduce infections. At that point, earlier predictions of substantial reductions in hospital revenue as a result of the policy may turn out to be accurate. [Authors] suggest that by
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Volume 52, Number 6, June 2014
focusing on ICUs alone, CMS could have saved as much as $95.6 million in 2009 from reducing payments for CAUTI. Given the complexities of separating all costs associated with a CAUTI from others, it is unlikely that aggregate payments would be lowered by this amount. However, findings for Pennsylvania hospitals suggest that mandatory reporting for hospitals with ICUs might save almost half of the projected amount. Still, improved reporting must be paired with vigorous enforcement if the nonpayment policy is to approach the potentially achievable savings. Attributing health care costs to a particular diagnosis or cause is difficult even for uncomplicated cases. For this reason it is possible that CMS may never be able to develop a payment method that completely eliminates the payment differential between patients with and without CAUTIs. However, there is room for substantial improvement. CMS is launching a new initiative later this year, using an approach for reducing CAUTI that avoids the difficulty of separating out CAUTI-related and non–CAUTI-related costs. Rather than focus on payments for individual CAUTI patients, CMS will reduce overall Inpatient Prospective Payment System (IPPS) payments for hospitals with high hospital-acquired condition rates. Using NHSN monitoring data, hospitals in the lowest performing quartile will see a 1% reduction in IPPS payment. CAUTI and central line–associated blood stream infections are weighted more heavily than other conditions when calculating hospital performance.15 Developing effective and efficient payment methods is an evolutionary process. Whether or not this new approach will incentivize all hospitals to reduce CAUTIs remains to be seen. If it is successful, hospital revenues may suffer somewhat, but patients will ultimately benefit from safer treatment and perhaps redeployment of savings to more effective and life-enhancing uses. Most likely, CMS and hospitals will continue to look for ways to further strengthen the link between payment incentives and better patient outcomes. REFERENCES 1. Center for Medicaid and Medicare. Hospital acquired conditions. 2012. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond/Hospital-Acquired_Conditions.html. Accessed February 28, 2014. 2. Centers for Disease Control and Prevention. Hospital infections cost US billions of dollars annually. Press release, March 6, 2000. Available at: http://www.cdc.gov/media/pressrel/r2k0306b.htm. Accessed February 28, 2014. 3. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health careassociated infections and deaths in US hospitals, 2002. Public Health Rep. 2007;122:160–166. 4. Roberts RR, Scott RD II, Hota B, et al. Costs attributable to healthcareacquired infection in hospitalized adults and a comparison of economic methods. Med Care. 2010;48:1026–1035. 5. National Archives and Records Administration. Federal Register. 2008. Available at: https://www.federalregister.gov/articles/2008/08/19/E817914/medicare-program-changes-to-the-hospital-inpatient-prospectivepayment-systems-and-fiscal-year-2009#h-62. Accessed February 28, 2014. 6. McNutt R, Johnson TJ, Odwazny R, et al. Change in MS-DRG assignment and hospital reimbursement as a result of Centers for Medicare & Medicaid changes in payment for hospital-acquired conditions: is it coding or quality? Qual Manag Health Care. 2010;19:17–24. 7. Saint S, Meddings JA, Calfee D, et al. Catheter-associated urinary tract infection and the Medicare rule changes. Ann Intern Med. 2009;150: 877–884. r
2014 Lippincott Williams & Wilkins
Medical Care
Volume 52, Number 6, June 2014
8. Rosenthal MB. Nonpayment for performance? Medicare’s new reimbursement rule. N Engl J Med. 2007;357:1573–1575. 9. National Archives and Records Administration. Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and Fiscal Year 2010 Rates and to the Long-Term Care Hospital Prospective Payment System and Rate Year 2010 Rates; Proposed Rule. Federal Register, 74. 2009. Available at: http://www.gpo.gov/fdsys/pkg/FR-2009-05-22/html/E9-10458.htm. Accessed March 5, 2014. 10. Peasah SK, McKay NL, Harman JS, et al. Medicare non-payment of hospital-acquired infections: infection rates three years post implementation. Medicare Medicaid Res Rev. 2013;3:E13–E15. 11. Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in US hospitals. N Engl J Med. 2012;367: 1428–1437.
r
2014 Lippincott Williams & Wilkins
Editorial
12. Daniels KR, Lee GC, Frei CR. Trends in catheter-associated urinary tract infections among a national cohort of hospitalized adults, 20012010. Am J Infect Control. 2014;42:17–22. 13. Meddings J, Saint S, McMahon LF Jr. Hospital-acquired catheterassociated urinary tract infection: documentation and coding issues may reduce financial impact of Medicare’s new payment policy. Infect Control Hosp Epidemiol. 2010;31:627–633. 14. Centers for Disease Control and Prevention. Reporting requirements and deadlines in NHSN per CMS current rules. 2013. Available at: http:// www.cdc.gov/nhsn/PDFs/CMS/CMS-Reporting-Requirements-Deadlines. pdf. Accessed March 5, 2014. 15. Centers for Medicaid and Medicare. Fact sheet: CMS final rule to improve quality of care during hospital inpatient stays. 2013. Available at: http://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2013fact-sheets-items/2013-08-02-3.html. Accessed March 5, 2014.
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481
Not Paying for Catheter-associated Urinary Tract Infections More Difficult Than it Seems? Robin E. Clark, PhD and Karen M. Clements, ScD
P
olicy interventions that attempt to influence patient care can be hard to implement and their desired outcomes can be slow to achieve. The efforts of the Centers for Medicare and Medicaid Services (CMS) to reduce preventable infections by withholding payment for additional expenses related to catheter-associated urinary tract infections (CAUTI) illustrate this challenge clearly. In October of 2008, CMS began a policy of refusing to pay hospitals for additional costs related to CAUTI and 7 other potentially preventable events or conditions. The list was expanded to include 3 new conditions in 2013.1 CAUTIs represent more than one third of all hospital-acquired infections and are costly to treat.2–4 Medicare patients appear to have much higher rates of CAUTIs compared with other groups.5 Initial reactions to the rule varied widely. Some observers predicted large reductions in hospital revenue6 and others suggested that hospitals might compensate by charging for more complicated conditions or comorbidities and by relying on outlier payments to cover additional time spent in the hospital to treat the infection.7,8 CMS predicted savings from the new rule of $21 million–$22 million per year between 2010 and 2014 from reduction in reimbursement for the 8 original hospital-acquired conditions combined.9 Follow-up studies using hospital discharge reports from a single state, the National Hospital Discharge Survey, or the National Healthcare Safety Network (NHSN), a reporting system maintained by the Centers for Disease Control, show that CAUTIs have not declined significantly since the policy was implemented.10–12 The study by [authors] suggests at least 2 reasons why the nonpayment initiative has not been more effective in reducing CAUTIs. The first problem was a flawed monitoring system. Any new policy must have a way to accurately track the behaviors it seeks to influence. As [authors] and others describe, CMS originally relied on International Classification of Diseases-9th revision (ICD-9) codes on Medicare claims to identify CAUTI; this method was ineffective because the codes required to identify CAUTI events were often not reported on claims. A further complication was introduced when CMS asked providers to report new “present on admission” codes after the 2008 implementation date. Any change that requires providers to record and report new data may take time to implement. Further, because claims are primarily used for paying providers, there was a weak incentive to record an unreimbursable condition. Moreover, earlier studies showed that catheter placement is not always recorded accurately in physician notes in medical records, which are the source of billing codes.13 To address the issue of underreporting in their analysis, [authors] used the NHSN to identify CAUTIs, then linked infection reports to Medicare claims to compare payments for patients with a CAUTI to a similar group without evidence of a urinary tract infection. Because the NHSN was specifically designed to monitor health care–associated infections, it was less likely to suffer from the type of underreporting observed in claims.
From the Center for Health Policy and Research, University of Massachusetts Medical School, Shrewsbury, MA. R.E.C. is a co-principal investigator for a grant application that is currently under review by the Centers for Medicare and Medicaid Services. K.C. declares no conflict of interest. Reprints: Robin E. Clark, PhD, Center for Health Policy and Research, University of Massachusetts Medical School, 333 South Street, Shrewsbury, MA 01545. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5206-0479
Medical Care
Volume 52, Number 6, June 2014
www.lww-medicalcare.com |
479
Editorial
The results of the analysis by [authors] suggest a second reason why the nonpayment rule has had little impact. Far from receiving no payment for CAUTIs, the study shows that hospitals have continued to receive substantially higher payments for them after the initiation of the 2008 policy. It is not clear how these payments compare with the actual cost to hospitals of delivering care. Possibly the higher payments did not cover the full costs of treating CAUTI. Nevertheless, the significantly higher payments reduced the financial consequences of CAUTI to hospitals and thus weakened the incentive to change their current practices. The mechanisms driving increased Medicare payments for CAUTI patients were predicted by some early prognosticators. Compared with their claims for similar patients without infections acquired during their stay, hospitals assigned more complex Diagnostic Related Group codes (DRGs), identified more co-occurring conditions, and billed more outlier payments to cover the significantly longer stays required to treat CAUTI patients. These are most likely real costs incurred by hospitals. [Authors] clearly show longer lengths of stay and that the patients involved have a number of co-occurring conditions or comorbidities that may or may not be related to CAUTIs but which raise the cost of care, perhaps justifying a shift to a higher weighted DRG. Given the challenges of identifying CAUTIs and of distinguishing between allowable expenses and those that are not reimbursable under the nonpayment rule, how might CMS improve monitoring and enforcement? A potential solution to the case identification problem is suggested by the methods used by [authors]. Indeed, in 2012, CMS began requiring all hospitals with intensive care units (ICUs), where the larger payment differentials are found, to report infections among ICU patients through the NHSN.14 By relying on NHSN reports rather than Medicare claims for case identification, CMS can identify cases with greater accuracy. [Authors] found higher odds of death among patients admitted to the ICU with a CAUTI (OR = 1.37). Although mortality was not elevated among cases from Pennsylvania, the only state in the sample where hospitals were required to report infections to NHSN, additional evidence supports the finding of increased mortality among CAUTI patients.3 A focus on patients in ICUs is likely to produce the greatest benefit. CMS will add a requirement to report all cases in adult and pediatric medical, surgical, and medical/surgical wards in 2015, which will allow identification of virtually all CAUTIs in acute care settings.14 CMS is still challenged with deciding how to pay hospitals for patients with complex conditions when there is a CAUTI. The Centers could deny outlier payments for stays that exceed the expected length when a CAUTI is identified. Cases in which the reasons for a longer stay were plausibly unrelated to a CAUTI might be subjected to appeal or a special review. The problem of how to determine which, if any, co-occurring conditions were likely related to the CAUTI remains a challenge. Improved reporting and monitoring of CAUTIs will increase transparency and apply greater pressure on hospitals to reduce infections. At that point, earlier predictions of substantial reductions in hospital revenue as a result of the policy may turn out to be accurate. [Authors] suggest that by
480 | www.lww-medicalcare.com
Medical Care
Volume 52, Number 6, June 2014
focusing on ICUs alone, CMS could have saved as much as $95.6 million in 2009 from reducing payments for CAUTI. Given the complexities of separating all costs associated with a CAUTI from others, it is unlikely that aggregate payments would be lowered by this amount. However, findings for Pennsylvania hospitals suggest that mandatory reporting for hospitals with ICUs might save almost half of the projected amount. Still, improved reporting must be paired with vigorous enforcement if the nonpayment policy is to approach the potentially achievable savings. Attributing health care costs to a particular diagnosis or cause is difficult even for uncomplicated cases. For this reason it is possible that CMS may never be able to develop a payment method that completely eliminates the payment differential between patients with and without CAUTIs. However, there is room for substantial improvement. CMS is launching a new initiative later this year, using an approach for reducing CAUTI that avoids the difficulty of separating out CAUTI-related and non–CAUTI-related costs. Rather than focus on payments for individual CAUTI patients, CMS will reduce overall Inpatient Prospective Payment System (IPPS) payments for hospitals with high hospital-acquired condition rates. Using NHSN monitoring data, hospitals in the lowest performing quartile will see a 1% reduction in IPPS payment. CAUTI and central line–associated blood stream infections are weighted more heavily than other conditions when calculating hospital performance.15 Developing effective and efficient payment methods is an evolutionary process. Whether or not this new approach will incentivize all hospitals to reduce CAUTIs remains to be seen. If it is successful, hospital revenues may suffer somewhat, but patients will ultimately benefit from safer treatment and perhaps redeployment of savings to more effective and life-enhancing uses. Most likely, CMS and hospitals will continue to look for ways to further strengthen the link between payment incentives and better patient outcomes. REFERENCES 1. Center for Medicaid and Medicare. Hospital acquired conditions. 2012. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond/Hospital-Acquired_Conditions.html. Accessed February 28, 2014. 2. Centers for Disease Control and Prevention. Hospital infections cost US billions of dollars annually. Press release, March 6, 2000. Available at: http://www.cdc.gov/media/pressrel/r2k0306b.htm. Accessed February 28, 2014. 3. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health careassociated infections and deaths in US hospitals, 2002. Public Health Rep. 2007;122:160–166. 4. Roberts RR, Scott RD II, Hota B, et al. Costs attributable to healthcareacquired infection in hospitalized adults and a comparison of economic methods. Med Care. 2010;48:1026–1035. 5. National Archives and Records Administration. Federal Register. 2008. Available at: https://www.federalregister.gov/articles/2008/08/19/E817914/medicare-program-changes-to-the-hospital-inpatient-prospectivepayment-systems-and-fiscal-year-2009#h-62. Accessed February 28, 2014. 6. McNutt R, Johnson TJ, Odwazny R, et al. Change in MS-DRG assignment and hospital reimbursement as a result of Centers for Medicare & Medicaid changes in payment for hospital-acquired conditions: is it coding or quality? Qual Manag Health Care. 2010;19:17–24. 7. Saint S, Meddings JA, Calfee D, et al. Catheter-associated urinary tract infection and the Medicare rule changes. Ann Intern Med. 2009;150: 877–884. r
2014 Lippincott Williams & Wilkins
Medical Care
Volume 52, Number 6, June 2014
8. Rosenthal MB. Nonpayment for performance? Medicare’s new reimbursement rule. N Engl J Med. 2007;357:1573–1575. 9. National Archives and Records Administration. Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and Fiscal Year 2010 Rates and to the Long-Term Care Hospital Prospective Payment System and Rate Year 2010 Rates; Proposed Rule. Federal Register, 74. 2009. Available at: http://www.gpo.gov/fdsys/pkg/FR-2009-05-22/html/E9-10458.htm. Accessed March 5, 2014. 10. Peasah SK, McKay NL, Harman JS, et al. Medicare non-payment of hospital-acquired infections: infection rates three years post implementation. Medicare Medicaid Res Rev. 2013;3:E13–E15. 11. Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in US hospitals. N Engl J Med. 2012;367: 1428–1437.
r
2014 Lippincott Williams & Wilkins
Editorial
12. Daniels KR, Lee GC, Frei CR. Trends in catheter-associated urinary tract infections among a national cohort of hospitalized adults, 20012010. Am J Infect Control. 2014;42:17–22. 13. Meddings J, Saint S, McMahon LF Jr. Hospital-acquired catheterassociated urinary tract infection: documentation and coding issues may reduce financial impact of Medicare’s new payment policy. Infect Control Hosp Epidemiol. 2010;31:627–633. 14. Centers for Disease Control and Prevention. Reporting requirements and deadlines in NHSN per CMS current rules. 2013. Available at: http:// www.cdc.gov/nhsn/PDFs/CMS/CMS-Reporting-Requirements-Deadlines. pdf. Accessed March 5, 2014. 15. Centers for Medicaid and Medicare. Fact sheet: CMS final rule to improve quality of care during hospital inpatient stays. 2013. Available at: http://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2013fact-sheets-items/2013-08-02-3.html. Accessed March 5, 2014.
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