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Antibiotics Stewardship Enters Play-to-Pay Arena

Analysis  |  By Philip Betbeze  
   April 07, 2016

Draft regulations from The Joint Commission say that all hospitals, regardless of size, must develop programs to combat antibiotic resistance. CMS is expected to follow that lead. Intermountain Health is already hard at work.

At some point in the very near future, your hospital may have to certify its adherence to a formal antibiotics stewardship program in order to receive reimbursement from Medicare.

Such rulings are known as conditions of participation. Meaning, if you don't participate, you don't get paid for treating Medicare patients.

But that's only the regulatory hammer that will ensure compliance. The real reason to get your antibiotics stewardship program under way is that it's one big piece of the puzzle toward combating antibiotic resistance, which is turning into a huge public health problem, says Edward Stenehjem, MD. He is medical director of the Urban Central Region Antimicrobial Stewardship Program and co-chair of the Antimicrobial Stewardship committee at Intermountain Healthcare in Salt Lake City.

Pushing back against antibiotic resistance is also a piece to the puzzle of your financial viability, given the increasing risk of infection from antibiotic-resistant pathogens that can wreck a reimbursement system that is moving closer to capitation.

Antimicrobial stewardship is the systematic effort to improve the quality of prescribing of antibiotics. It's useful not only in improving clinical outcomes, but also in attempting to decrease antimicrobial resistance and adverse events. Drug-resistant bacteria are on the rise, and hospitals are ground zero.

There are only a few ways to slow this trend, Stenejhem says.

"The most important is improving antibiotic use, and we do that through optimizing prescribing. There's not going to be a day where we don't use these drugs. They're miracle drugs, they're curative," he says.

"Regardless of appropriateness of use, their use will always drive resistance. The challenge is to use the least amount that's clinically necessary to slow antibiotic resistance."

At its current rate, matching the rise of resistance with new drug development and delivery is a losing battle, he says, making stewardship even more important.

'A Public health Issue'
Although development of stewardship programs is only one piece of the puzzle, it's the piece over which readers of this space have the most control and influence. But it requires a coordinated effort. Outpatient prescribing and rampant antibiotic overuse in livestock are other targets if an appreciable impact on resistance levels is to be achieved.

"This isn't a single-center issue. In order to have an impact, every hospital has to have program to address this," says Stenehjem. "It does us no good in the Salt Lake Valley if two hospitals prescribe appropriately when the other hospitals don't have these programs. So really, this is a public health issue."

That's one reason Stenehjem is speaking out, as an effort to help educate other healthcare organizations that perhaps don't know where to start. Intermountain uses a variety of well-tested techniques to encourage appropriate antibiotics use by its prescribing clinicians at all of its hospitals, and is willing to share advice and techniques.

That's a valuable resource, he says, because soon operating such programs won't be voluntary.

Stenejhem expects antibiotic stewardship programs to be mandatory, likely by 2017. In December 2013, a presidential executive order directed National Security Council staff to define strategies to conduct antimicrobial resistance prevention. Following the release of a report on how to address this, a 2015 national action plan was developed to combat antimicrobial resistance.

In that strategy, one of the core recommendations was to make antimicrobial stewardship mandatory under a CMS condition of participation. In November 2015, The Joint Commission released draft regulations mandating every hospital, regardless of size, to have to have stewardship programs. Stenehjem expects final language from the body on those regulations will be in effect by 2017.

"We've not heard from CMS about the condition of participation part, but we are fairly certain that will soon follow as well," he says. "The writing's on the wall. You'll have to meet these requirements."

There are costs involved, of course, mostly in labor, but also in technology, but Stenehjem says they're well worth it. "We improve quality, outcomes, and decrease costs through this," he says. "That's a pretty small price to pay in terms of staffing."

And that price starts looking even smaller when you start to think about moving toward different reimbursement models—ones that incorporate ACOs and population health and capitation.

C. diff Infection Raises Hospital Costs by 40% per Case

"Think about what is the cost to your organization from an outbreak of drug-resistant bacteria. You get one patient with severe c-diff infection and you have to remove part of their colon. The cost from adverse events far outweighs the cost of salaries for infectious disease physicians and pharmacists to develop these programs," says Stenehjem.

Further, it's just the right thing to do because there's hard evidence that such programs reduce costs and mortality.

It's challenging to say the least though, when you talk about the cost of such programs in small community hospitals. Some 70% of hospitals in this country have less than 200 beds. That's too small to hire an infectious disease clinician. "We have 15 such hospitals," says Stenejhem.

So how do they do stewardship?

Intermountain just completed a randomized control trial in those facilities to get at the optimum way to do that stewardship there. Stenehjem says the health system is still crunching the data at this point, so conclusions haven't yet been drawn or publicized, but doing stewardship at such facilities is "feasible and warranted," he says.

"Within our network, those facilities have access to infectious disease experts through a telehealth model, but others don't necessarily have those resources."

Moreover, Stenehjem says his job and the responsibility of clinicians like him is to make sure appropriate prescribing is made easy for the physician, that there are electronic care pathways that guide physicians to most appropriate care, and that care processes and models are derived and reviewed by the infectious disease and stewardship departments to understand whether they are being prescribed at the right dose and duration and route.

"This is a very collaborative effort and we're getting everyone to understand that these drugs are not benign," he says.

Intermountain posts transparent report cards for all the clinicians so they can see how they're doing on antibiotic stewardship in comparison with their peers and the system average. Intermountain recognizes high performers, and peers can see their names and their prescribing patterns.

He concedes there's not enough talent in the area of infectious disease and microbial stewardship, but that it's possible to extend the talent that there is.

"It's also important to develop physician champions who are not infectious disease clinicians," he says. "That means hospitalists and internal medicine folks. Those physician leaders understand the clinical consequences of drug resistant bacteria. It's a sad case that medicine continues to push boundaries and innovate, but if we are not careful, we may get to a point where all innovation will be undermined by drug resistance. Preventing and treating infections goes hand-in-hand with surgery. Failure to get a handle on this will limit our ability to innovate."

Philip Betbeze is the senior leadership editor at HealthLeaders.

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