Inconvenient truth: The profit of some infections
Patient safety groups demand action, accountability
While the exorbitant costs of health care associated infections (HAIs) have been repeatedly cited as a prime reason for prevention — second only to the higher calling of patient safety — a somewhat shocking finding came out in a 2013 study by the respected Peter Pronovost, MD, and colleagues.1
As previously reported in Hospital Infection Control & Prevention, they found that hospitals actually profit from infections in certain circumstances due to misaligned incentives in the payment system that reward higher payments for complications and outlier cases. (See HIC, July 2013 p. 79.)
"I have to agree with Peter — I don't think our system has it right yet," says Denise Murphy, RN, MPH, CIC, Vice President of Quality and Patient Safety at Main Line Health in suburban Philadelphia. "We still pay for harm and waste, but that is changing. We understand that we are getting penalized and we will soon start to see less reimbursement for harm through CMS Value Based Purchasing."
That said, and taking the moral and ethical imperatives out of the equation for a second, it is still better in the grand economic scheme of things to get patients discharged and free up hospital beds.
"You make better money when you open up the flow, when you have new patients coming through the beds," Murphy says. "Nothing supports the bottom line better than volume. When you have stagnant volume with people lying in beds as a result of infection in an ICU or a patient unit your reimbursement is going to drop lower at some point — once the patient has been in the bed too long. Then you are losing money on them being hospitalized. We are getting penalized on our insurance contracts for long lengths of stay right now, but the inverse side of that is you are also still getting paid something. It's both sides of the coin, we are being penalized and we are being rewarded. The payment system needs to be better aligned."
As that process continues, the business case for infection prevention will become clearer, creating distinct incentives for program support.
"That really started showing the benefit of infection prevention to organizations, so that's the carrot," Murphy says. "The stick is the national move toward public reporting, the CMS starting to pay for performance and putting infections in the list of Hospital Acquired Conditions (HACs)."
HACs are essentially conditions that were not present on admission, with infection deaths representing roughly half of the 200,000 people who die every year in U.S. hospitals from medical errors and other HACs. These conditions are increasingly seen as preventable, and thus the growing reluctance to reimburse hospitals for treating them.
'Uh, we burned up yor car. Here's the bill.'
"Can you imagine taking your car in for service, and the service station sets your car on fire accidentally and then asks you to still pay for the service you brought it in for and the fire extinguisher costs they had to use to put out the fire?," says Joe Kiani, founder of the Patient Safety Movement Foundation. "That's unfortunately what happens in our care system."
Kiani's group has set a goal for zero preventable hospital deaths by 2020, telling HIC if "the government would create incentives for all hospitals to get on board with this goal, we could get there much faster." The patient safety foundation is calling on Congress to expand the current HAC Medicare policy to include a list of causes of preventable death, he says. The group is creating Actionable Patient Safety Solutions (APSS) for some hospital acquired conditions, including CLABSIs.
"The Affordable Care Act addresses this in part by creating new penalties for HAIs but penalties alone will not fix this problem," says Kiani, founder and CEO of Masimo Corp in Irvine, CA. "We need to align the incentives so that hospital administrators are driven to put systems in place to prevent these avoidable harms and deaths."
In that regard, the patient safety group is lobbying Congress to suspend payment for even the primary condition until it is determined whether the cause of death was preventable.
"If preventable, and the hospital has implemented evidence based strategies for prevention, such as those indicated by the APSS, the hospital would receive payment for the primary condition," he says. "If the hospital had not implemented the strategy, then payments for both the primary and secondary conditions would be denied."
That would certainly create pressure to adopt infection prevention and patient safety measures, and hospitals that act in good faith to do so should not be liable for HACs, he says. "If hospitals implement evidence-based practices, they should be shielded from malpractice lawsuits to the fullest extent possible, such as through an affirmative defense and limits on damages," Kiani says.
'People go bankrupt, they lose their homes'
Another national patient safety group, the Consumers Union, publishers of Consumer Reports, is also demanding accountability by hospitals for HAIs.
"It's certainly accurate to say that hospitals get paid for taking care of those patients that they harm," says Lisa McGiffert, director of the Safe Patient Project at the Consumers Union. "I think the way we pay for health care is so complicated that in some cases it is profitable and in some cases it probably isn't. If the hospital caused the infection we are not even touching the surface of the full cost to the patient because for example, the CMS hospital acquired infection policy just covers that hospitalization. So if the patient ended up leaving and they are coming back in because the infection got worse or whatever that second hospitalization would be paid for. Then of course there are all kinds of services that patients need to recover from infections including wound care, drugs, doctor visits and physical therapy. That can go on for years and nobody is really making hospitals accountable for that. A lot of people go bankrupt, they lose their jobs, their homes. Nobody is making anybody responsible for that."
However, there are some positive signs in that direction, including the ongoing Patient Safety and Medical Liability Initiative, Kiani says. Funded by the Agency for Healthcare Research and Quality (AHRQ), the research program is developing systems to inform injured patients and families promptly when an adverse event like an HAI occurs. The idea is to promote transparency and enhanced communication between providers and patients when avoidable harm occurs, an approach that may actually reduce liability because patients may be less likely to sue if they get full disclosure and an apology.
"Hospitals want to do the right thing, but we just need to make sure that incentives and protections are in place to allow them to do so," Kiani says.
- Hsu E, Lin D, Evans SJ, et al. Doing Well by Doing Good: Assessing the Cost Savings of an Intervention to Reduce Central LineAssociated Bloodstream Infections in a Hawaii Hospital. Amer Jrl Med 2013; published online 7 May 2013 DOI:10.1177/1062860613486173