CMS changes could spell unintended consequences

What about immune-compromised patients?

The Centers for Medicare & Medicaid Services (CMS) decision to halt payment on additional costs generated by certain infections could unleash a series of unintended consequences such as increased testing and possible inappropriate treatment for hospital patients on admission, a health care epidemiologist warns.

In addition, the CMS changes do not address the fact that not all of infections are preventable, meaning a hospital may not be reimbursed for a costly infection it did everything scientifically possible to prevent, says Tammy Lundstrom, MD, JD, who spoke on behalf of the Association for Professionals in Infection Control and Epidemiology.

CMS says its recently issued final rule takes significant steps to improve the accuracy of Medicare's payment under the acute care hospital inpatient prospective payment system (IPPS), while providing additional incentives for hospitals to engage in quality improvement efforts. The IPPS payment reforms would restructure the inpatient diagnosis-related groups (DRGs) to account more fully for the severity of each patient's condition. In addition, the rule includes important provisions to ensure that Medicare no longer pays for the additional costs of certain "preventable conditions" including infectious complications of mediastinitis, catheter-related urinary tract infections, and catheter-related vascular infections.

"What I am concerned about is that everybody who comes into the hospital is going to get a urine culture to [determine if] they had bacteria when they came in," Lundstrom tells Hospital Infection Control. "That is a concern, because lots of women have bacteria in their urine, but are totally asymptomatic and shouldn't be treated. So if that is the strategy a lot of hospitals take it could cause a lot of people to get unnecessary antibiotics. That is one of the unintended consequences of this CMS approach."

In addition, a recent study showed that high-risk patients still acquired mediastinitis heart-related infections despite the best efforts of clinicians.1 "These are not completely preventable even with all the best science," she says. "Even with doing all of the SCIP [Surgical Care Improvement Project] measures they still had a number of cases of mediastinitis infection after coronary artery bypass. They did everything to prevent the infection and it still occurred. It is a tragedy for the patient but there is nothing that the hospital could have done differently. In this new CMS world they wouldn't get paid for it. There is an appeal process but it's really cumbersome. So whether individual hospitals will appeal or not remains to be seen."

Indeed, it is not as if the cost of mediastinitis infections are already being fully reimbursed, adds William Scheckler, MD, hospital epidemiologist at St. Mary's Medical Center in Madison, WI.

"We found in an [unpublished] study some years ago that the actual charges for mediastinitis that were not reimbursed by Medicare were around $45,000 per patient," he says. "They don't want to pay extra for it, but they are already not paying extra for it. I'm sure they are fine tuning it. Do we want a patient in our hospital to have mediastinitis? Of course not. They [use] terms like 'quality' or 'pay for performance,' but the bottom line is they are trying to control costs. They don't want people adding complexity or readmission complexity to the current DRG codes."

There is concern that such pay-for-performance measures will make hospitals reluctant to offer special treatment programs to severely immune compromised patients with little protection against infections.

"For example, bloodstream infections," Lundstrom says. "If I have a facility that has a bone marrow transplant unit, those patients have no defenses against infection. I have a burn unit and those patients have a much higher rate of infection than your average hospital patients. Will this disincent hospitals from having burn units and bone marrow transplant centers?"

Professional societies such as APIC are working with CMS to exclude such patients from the rules so hospitals are not penalized for treating patients with little defense against infections. "APIC is all about preventing infections, but we are concerned with the multiple things that are changing at once [in the CMS rules]," she says. "The impact of this is really not truly known at this time."

Other conditions targeted by Medicare for non-reimbursement include pressure ulcers, injuries caused by patient falls, and "serious preventable events" such as leaving an object in a patient during surgery, air embolism, or administering incompatible blood products. The new rules will go into effect in October 2008.


  1. Fakih MG, Sharma M, Khatib R, et al. Increase in the rate of sternal surgical site infection after coronary artery bypass graft: A marker of higher severity of illness. Infect Control Hosp Epidemiol 2007; 28:655-660.