Special Report: Infection Control and Managed Care

Professional crossroads: ICPs can either grow their jobs or lose autonomy

Those who seize opportunities will emerge as valuable players

Ongoing health care delivery changes in the managed care era are having a profoundly mixed impact on infection control and health care epidemiology, opening up new opportunities in surveillance and prevention for some programs while undercutting the infrastructure of others. Amid the continuing shakeout, however, there is a general consensus that infection control professionals can play critical roles in a health care system where traditional boundaries are blurring, experts advise Hospital Infection Control.

"I think the expertise of infection control personnel is more important now than ever," says Julie Gerberding, MD, MPH, the new director of the hospital infections program at the Centers for Disease Control and Prevention. "The traditional activities need to be expanded, and they are the only people who really have the expertise to do this." (See interview with Gerberding, p. 186.)

Indeed, there have been ongoing discussions about whether ICPs should redouble efforts to preserve and enhance their traditional roles or begin delving into other clinical areas (i.e., noninfectious adverse outcomes) to enhance their perceived value and job security. Regardless, the professional self-assessment forced upon the field by health care delivery changes ultimately may have its benefits.

Keep up or be left behind

"It is a catalyst to become even more creative and insightful," says Janet Franck, RN, MBA, incoming president of the Association for Professionals in Infection Control and Epidemiology (APIC), based in Washington, DC. "The profession is really beginning to determine whether or not its focus should continue to be dedicated to infection control, or whether we should look at becoming more versatile in other areas. This should be perceived as an opportunity, because if you look at the health care industry today, the needs are not necessarily what they were years ago — even just a few years ago. So we have to be dynamic and changing along with the health care industry. Because if we don’t keep up with it, we are going to be left behind."

In that regard, ICP lecturers and consultants on economic issues are increasingly emphasizing that the field must shift to a "bottom line" business orientation in today’s health care climate.

"If we don’t become business-oriented, my personal opinion is that potentially within 20 years, we might not even have a profession," says Robert Garcia, MT (ASCT), CIC, assistant director of infection control at Brookdale University Hospital and Medical Center in New York City. "We might be absorbed in other areas — quality assurance, for example — and we will no longer have any autonomy."

Recent efforts to codify practice standards and outline the necessary infrastructure for infection control programs can be seen as an effort to define and defend the profession amid ongoing changes in health care delivery.

In a joint project with Canadian colleagues, APIC is drafting professional standards that include essential practice skills and outline a code of accountability and ethical conduct for today’s ICP. In addition, earlier this year a consensus panel issued a landmark report on the necessary infrastructure for the modern infection control program.¹ (See HIC, April 1998, pp. 51-56; August 1998, pp. 120-121.) ICPs report their programs are meeting the clinical recommendations in the infrastructure report, but some are struggling with a lack of clerical services and technological support. (See related story, p. 182.)

"Managed care" has become the general catch phrase for health care delivery changes driven by the ascension of prepaid group insurance plans over the traditional fee-for-service model. In general, such managed care organizations — whether health maintenance organizations (HMOs), preferred provider organizations (PPOs), or point-of-service (POS) plans — focus on patient populations, networks of providers, and a controversial effort to reduce costs while maintaining or improving the quality of care. A widely reported result of these health care delivery changes is reduced census in acute care hospitals, with all but the sickest patients dispatched to an expanding continuum of outpatient services, clinics, and home care.

Fueled in part by consumer backlash and a desire for more flexibility in choosing medical providers, the rapid growth of HMOs has slowed in recent years, explains Don White, spokesman for the American Association of Health Plans (AAHP) in Washington, DC. Still, according to data from a 1997 national survey of employer-sponsored health plans (all employers in the United States with 10 or more employees), only 15% of employees were enrolled in traditional fee-for-service plans.² That figure was 52% as recently as 1992. Overall for 1997, 85% of employees in the companies surveyed were enrolled in a managed care plan, with 35% in PPOs, 30% in HMOs, and another 20% in POS plans.

"People get real enthralled with that number — 85% is a big number," White says. "But HMO enrollment has been flat the last couple of years. The largest growth has been in PPOs and point-of-service plans, both of which by their very structure give people added flexibility to go outside of the network whenever they want to. That is where the growth has been. And even in the HMOs, there is a lot of emphasis on flexible referral systems. We’re not going to 100% [market penetration], because what we are seeing is the development of these new more flexible plans. So it is not the kind of juggernaut it is perceived to be."

IC in a changing delivery system

The ongoing health care delivery changes are having a mixed overall impact on both ICPs and infection prevention efforts in the nation’s hospitals, Gerberding says.

"There have been inconsistent effects of managed care on issues that really pertain to staffing and resource management," she says. "There are some very competitive for-profit managed care organizations that have more or less slashed their infrastructure to cut their overhead in the short run. Some infection control programs and infection control practitioners have been affected by that."

In addition, there have been trends toward more consolidation in health care, with reorganizations and staff cuts resulting in fewer clinicians being responsible for more patients in a larger array of venues, she explains.

"That certainly has an impact on the day-to-day life of [infection control] practitioners and epidemiologists," Gerberding says.

In contrast, the CDC emphasized in its recently updated emerging infections plan that the new managed care environment provides unique opportunities for infection surveillance and prevention through interlinked databases and implementation of infection control measures over large patient populations and multiple institutions.³ (See related story, p. 179.)

"So on the one hand, there are economies of efficiency, like access to information systems and much more efficient ways of monitoring populations, [but] the personnel resources available to do that have not necessarily been preserved and protected," Gerberding says. "There are some managed care organizations, on the other hand, that really recognize the long-term added value of having a quality improvement program that includes strong surveillance and control of nosocomial infections. So some [ICPs] have benefited, but others have not."

Staffing, IC outsourcing increasing risk?

In addition, the CDC is concerned that efforts to contain costs as part of health care delivery changes in such systems may actually increase the risk of nosocomial infections. The impact of staffing changes on infection rates, for example, is being studied as part of the CDC-funded "Epi Center" clinical research projects at participating hospitals and health care systems. (See HIC, May 1998, pp. 72-74.)

"One of the Epi Center projects is looking at the impact of patient-nurse ratios in intensive care units on the incidence of bloodstream infec tions and other adverse outcomes," says Gerberding. "We are interested in looking at the overall impact of staffing and access to infection control expertise on nosocomial infections."

A previously published CDC study on the issue concluded that "during health care reform, as hospitals downsize their staff in efforts to contain rising health care costs, reduced staffing should be considered a potential risk factor for nosocomial infections."⁴ (See HIC, June 1996, pp. 69-72.) More recently, researchers in Canada have linked health care delivery changes similar to those occurring under managed care in the United States to an increase in bloodstream infections in hemodialysis patients.⁵ (See related story, p. 189.)

"Health care reform is also affecting the number of nurses. Non-nursing personnel are taking care of patients," warned William Jarvis, MD, chief of the investigations and prevention branch of the CDC hospital infections program, earlier this year in Orlando, FL, at the annual conference of the Society for Health care Epidemiology of America (SHEA). ". . . The level of training of the person providing the health care [is] decreasing, and as a result the infection risks for our patients are increasing. It also provides an even greater challenge for us in our education processes in that many of the nursing personnel that we have dealt with in the past have had a basic understanding of infection control. Now we are dealing with personnel that may not have that."

Jarvis also expressed concern that health care consolidation is displacing the traditional hospital-based infection control program in favor of a consulting arrangement where ICPs provide services for several institutions.

"As these hospitals merge and become smaller, particularly in the large for-profit organizations, it becomes very attractive to have one hospital epidemiologist or one infection control practitioner taking care of three, four, or five hospitals now and becoming a consultant," he told SHEA attendees.

Making money from nosocomial infections

The future levels of support for infection control programs in a changing health care delivery system may be influenced greatly by a bottom-line question: Who covers the costs of nosocomial infections?

"You never heard of a hospital that gave someone an infection and said, Our fault — the rest of the stay is free,’" says Michael Millenson, health care analyst with human resources consultants William M. Mercer Inc. in Chicago. "It’s not like a bad meal in a restaurant. Therefore, hospitals in fact have made money off infections, and that’s the hard truth. Because the more services used, the more money."

On the other hand, under a managed care contract arrangement in which the hospital assumes all or a portion of the risk of additional costs due to nosocomial infections, there will be clear incentives to support infection prevention programs, he notes. Likewise, managed care’s focus on "efficiency" — which includes an emphasis on earlier discharge of patients while using fewer services to achieve the same clinical result — provides incentives to reduce nosocomial infections.

"That gives both the hospital and the managed care company an incentive to reduce infections," he says.

Under such a scenario, ICPs should be able to play a vital role in the evolving health care system, notes Millenson, author of the recently published book, Demanding Medical Excellence: Doctors and Accountability in the Information Age.⁶

"I think it’s fair to say infection control professionals are going to be more and more valuable players in the years ahead," Millenson says.

Under the fiscal pressures of a competitive, changing marketplace, hospital and health care systems ultimately will assess which of their programs help them accomplish one basic goal: higher quality of care at a lower cost, White adds.

"I think there are some exciting things going on now that have been driven by marketplace pressures," White says. "What that translates to really is that hospitals, HMOs, doctors, and nurses are accountable. When what you do is being measured — when someone is looking over your shoulder — you are probably not going to like it, but you are going to improve."

The AAHP argues that things are indeed improving, citing a 1997 study that found that for 18 of 24 indicators of quality of care, an HMO provided care as good or better than care provided in other settings.⁷ However, another study that found that chronically ill patients who were either elderly or poor had worse self-reported physical outcomes in HMOs than in fee for service plans.⁸

While Millenson concedes that managed care is not without its problems, he says more often than not the identified deficiencies draw more attention than the successful outcomes.

"When managed care is mismanaged, people yell long, hard, and loudly," he says. "When it is managed correctly, often it gets no credit. It’s not human nature to hold a press conference and announce that you are doing better than when you were left on your own."

References

1. Scheckler WE, Brimhall D, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: A consensus panel report. Infect Control Hosp Epidemiol 1998; 19:114-126.

2. William M. Mercer Inc. Mercer/Foster National Survey of Employer-sponsored Health Plans. Washington, DC; 1998.

3. Centers for Disease Control and Prevention. Preventing emerging infectious diseases: A strategy for the 21st century. Overview of the updated CDC plan. MMWR 1998; 47(No. RR-15):1-14.

4. Fridkin SK, Pear SM, Williamson TH, et al. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996; 17:150-158.

5. Taylor GD, McKenzie M, Buchanan-Chell M, et al. Central venous catheters as a source of hemodialysis-related bacteremia. Infect Control Hosp Epidemiol 1998; 19:643-646.

6. Millenson M. Demanding Medical Excellence: Doctors and Accountability in the Information Age. Chicago: University of Chicago Press; 1998.

7. Miller RH, Luft HS. Does managed care lead to better or worse quality of care? Health Aff 1997; 16:7-25.

8. Ware JE Jr, Bayliss MS, Rogers WH, et al. Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. Results from the medical outcomes study. JAMA 1996; 276:1,039-1,047.