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'No-Pay' Policy for HAIs Does Not Reduce Infections

 |  By cclark@healthleadersmedia.com  
   October 11, 2012

A Harvard study raises questions about whether paying for performance—or penalizing hospitals for poor performance—improves quality of care.

The researchers examined whether the federal policy that took effect Oct. 1, 2008 prohibiting reimbursement for acute care services necessitated by hospital-acquired bloodstream or urinary tract infections provoked those infection rates to decline.

It did not, the researchers concluded in an article published Thursday in the New England Journal of Medicine.

"It surprised us a little bit," says Ashish Jha, one of the authors and the Associate Professor of Health Policy and Management. "I had hoped that by taking away the extra payments that hospitals used to get for (taking care of patients with) hospital-acquired infections, we would focus hospitals more on getting rid of these infections."

In fact, a variety of incentive programs to reduce  catheter-associated urinary tract infections and central line blood stream infections had been coming down independently prior to Oct. 1, 2008, the authors acknowledge, perhaps in anticipation of Medicare's penalty provisions, set forth in a section of the 2005 Deficit Reduction Act. 

But measured for each quarter from January, 2006 to March of 2011, the researchers found no change in the downward trajectory after the penalty took effect. They used a representative sample of 398 hospitals in 41 states.

"A lot of activities have resulted in these numbers going down," Jha says, including checklist recommendations from Johns Hopkins intensivist Peter Pronovost, MD. "We were trying to ask whether the 2008 policy impacted the rate of that change. We found pretty clear evidence that the policy did not have much of an impact."

The researchers postulated three reasons why hospitals didn't seem to respond to the penalty. 

First, it may be an artifact from more accurate coding. Hospitals may have been more careful to reflect when a patient came into the hospital with an infection present on admission, which would not be penalized, if that was indeed the case, rather than acquiring it while in the hospital.

Second, they wrote, these two infections were already targeted as part of other improvement initiatives nationally, through quality improvement organizations, accreditation agencies and other efforts.

Third, the financial penalty has reportedly been relatively insignificant, "as little as .6% of Medicare revenue for the average hospital...Hospitals may not have made additional investments in prevention of infection."

Asked if the CMS penalty for a hospital-acquired infection should be higher, Jha replied, "My personal opinion, not speaking for our group, is that these incentives are very weak, with very small amounts of money on the table.

And I do think we could make the incentives more stringent. For example, CMS could say 'we won't pay for that hospitalization at all."

"The hospital would comp the whole service. If CMS really wanted to shake things up, that would be one potential way," Jha added.

The bottom line, Jha says, "is that we should try things that I think are a little bit bolder and more substantial to see if they work or not. It clearly should be part of the agenda."

The Harvard report, prepared with researchers from the Institute for Healthcare Improvement, Harvard Pilgrim Healthcare, Boston Children's Hospital, and the Centers for Disease Control and Prevention, validates a 2009 study in the journal Health Affairs by researchers at UC San Francisco. That study predicted a negligible impact on hospital payments for care.

"Payment reductions were negligible, (.001%, or $.1 million—equivalent to $1.1 million nationwide) and are unlikely to encourage providers to improve quality," they wrote.

However, Harvard researchers may be confounded by results of a study published in the Journal of the American Medical Associationin May, 2012.

That report said that because of the no-payment policy, 81% of infection control experts said they were much more likely to focus on preventing hospital acquired infections, although only 15% said their organizations spent more money on it.

Those responding to the survey reported, however, that they were much more likely to remove urinary and central venous catheters when no longer needed to reduce the chance of infection and resource shifting was more common.

Jha and colleagues want policymakers to consider the impact these penalty and incentive initiatives are having on health outcomes before expanding the program to other aspects of care.

"For example," they wrote, "despite widespread adoption for pay-for-performance programs by health plans over the past decade, the evidence that they improve patient outcomes, either in primary care settings or hospital settings, is mixed.

Furthermore, the implementation of pay-for-performance programs has not been shown to be efficient or cost-effective."

Additionally "lingering concerns" remain that such penalties, more likely when providers take care of sicker patients, "may lead providers to avoid the most seriously ill patients, which may mitigate any intended beneficial effect of these programs."

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