- Since CMS stopped paying for HAIs in 2008, hospitals must absorb the cost of treating many healthcare-associated infections (HAIs).
- CMS can penalize 1% of all claims for bottom performers in infection prevention.
- Just one catheter-associated urinary tract infection costs a hospital nearly $14,000 more on average.
In this interview, Susan Bleasdale, MD, medical director of infection prevention and control and antimicrobial stewardship at UI Health in Chicago, describes the financial benefits of targeting healthcare-associated infections (HAIs).
On how infections affect the bottom line. Beyond affecting clinical outcomes, HAIs can have significant financial impacts, Bleasdale said. In 2008, the Centers for Medicare & Medicaid Services (CMS) stopped paying for HAIs, so now hospitals are on the hook for the costs.
The Agency for Healthcare Research and Quality estimates that each catheter-associated urinary tract infection (CAUTI) costs a hospital an additional $13,973 on average. For central line-associated bloodstream infections (CLABSIs), the additional costs climb to $48,108 per case, on average. Clostridium difficile, also known as C. diff, infections add another $17,260 per case on average, while each surgical site infection (SSI) costs an additional $28,219 on average.
And since the advent of the Hospital Value-Based Purchasing (VBP) program in 2012, HAIs have been affecting hospitals’ bottom lines in other ways, Bleasdale said. Specifically, through CMS’s Hospital-Acquired Condition Reduction Program (HACRP), organizations that perform in the bottom quartile on HAIs will be penalized 1% of their Medicare reimbursement two years later. So, hospitals that were in the lowest quartile of performance in FY18 will have 1% of their Medicare reimbursements withheld in FY20.
And when it comes to Medicaid, many states also deny payment for some preventable conditions like HAIs, Bleasdale said. Given these significant clinical and financial implications, finance leaders should ensure their organizations have the proper staff and infrastructure to tackle these infections.
“Making sure that you have a robust infection prevention program can impact your overall reimbursement at the patient level from an outcomes perspective and also at the system level, from a Medicare and Medicaid reimbursement perspective,” Bleasdale said.
On progress toward reducing HAIs. After CMS stopped paying for HAIs and implemented the VBP program, many hospitals focused on reducing CLABSIs and CAUTIs, Bleasdale said. Research shows they have made some progress. She points to a 2013 study that found a 43% reduction in vascular catheter-associated infections (which includes CLABSIs) after the VBP program was implemented (Peasah, S.K., McKay, N.L., Harman, J.S., et al., “Medicare non-payment of hospital-acquired infections: Infection rates three years post implementation,” Medicare & Medicaid Research Review, 2013). However, the study did not show a drop in CAUTIs, which Bleasdale said are more difficult to correctly identify from chart abstraction than they are through direct clinical care.
On engaging staff. Leaders should recognize that the key to reducing these infections is engaging physicians, nurses and other team members, Bleasdale said. In fact, she credits a highly motivated staff at UI Health for reducing its rate of CLABSIs and CAUTIs by 60% from 2012 to 2014. “We had everyone engaged and that made a difference in getting people to pay attention to these issues and help prevent infections,” she said.
How they did it: After joining UI Health in 2012, Bleasdale’s team formed a taskforce and gained C-suite support for their infection-control initiatives. “Because it affected our bottom line and patient outcomes, these initiatives became hospital priorities,” she said. “That gave us the resources to create the teams to support this.”
Unlike some organizations that follow a Comprehensive Unit-based Safety Program (CUSP) model that focuses on initiatives at the unit level to improve performance, UI Health implemented a broader infection control and prevention program organization-wide.
One of their most successful initiatives involved members of leadership, who rounded on the floors to question staff on why some patients still had a central line. Here, front-line engagement at the point of care created the positive change. “Education is important, but education does not always have a sustained impact,” she said. “Didactic lectures [on infection control] during grand rounds may not stick with people, but if you are engaging people at the actionable moment, that makes a difference.”
Currently, UI Health is in the top performance quartile for CLABSIs and CAUTIs in the VBP program. As such, they have not had a penalty and only have a limited number of HAIs that are not reimbursed. “Overall, we have a better bottom line because of that performance,” Bleasdale said.
On new HAI targets. In 2017, the VBP program added C. diff infections and SSIs so hospitals have more targets for avoiding Medicare penalties.
Currently, Bleasdale’s team is partnering with infectious disease pharmacists on a strategy to reduce inappropriate C. diff testing in which they ask providers to reconsider ordering laxatives in some patients. Research shows that laxatives often trigger a higher than normal rate of false positives for C. diff.
On components of an effective infection-control program. In Bleasdale’s view, one of the keys to reducing infections is to have an infection disease physician who is responsible for leading the organization’s infection control and prevention team.
This physician also can champion the organization’s antimicrobial stewardship efforts. The CDC estimates that 20% to 50% of antibiotics prescribed in hospitals each year are unnecessary, and antimicrobial stewardship can help hospitals reduce that number, Bleasdale said.
Robust data collection is also critical to improve performance. At UI Health, leaders rely on a data-mining program to help them collect HAI data, which they report to the CDC’s National Healthcare Safety Network. Bleasdale also works with her organization’s analytics team to build dashboards with real-time HAI data that they can share with leaders and frontline staff.
In an organization’s HAI improvement efforts, a strong clinical documentation improvement (CDI) team also can be a valuable asset. “Having a robust CDI team is critical because HAIs affect your billing at the individual patient level and also your performance in other quality measures,” she said. Ideally, the CDI team should be integrated with the hospital’s quality improvement team to help improve performance.
On what else infectious disease specialists can do. A growing body of research also suggests that early intervention by an infectious disease specialist can improve clinical and financial outcomes, Bleasdale said.
A 2018 study, found that getting infectious disease specialists involved early on in inpatient care was associated with nearly 23% shorter hospital stays (Schmitt, S., MacIntyre, A.T., Bleasdale, S.C., et al., “Early infectious diseases specialty intervention is associated with shorter hospital stays and lower readmission rates,” Clinical Infectious Diseases, Jan. 7, 2019). In addition, costs were almost $11,000 less for patients who were seen by an infectious disease specialist early in their hospital stay, compared with those who were not seen by an infectious disease specialist. Infectious disease consultations also were associated with lower 30-day readmissions and lower costs 30 days post-discharge.
Advice for finance teams. Bleasdale sees a role for finance leaders to participate on infection control and antimicrobial stewardship taskforces. In particular, they can help ensure that clinical teams have the time and resources they need to work on these activities.
“It takes investment in resources to have a robust and effective infection control and prevention program, as well as antimicrobial stewardship,” Bleasdale said. “But there is a high rate of return on that investment because if you are decreasing infections, you are decreasing patient care costs. And with the VBP program, you are affecting your reimbursement for other patients two years later. Small investments in personnel and infrastructure have a big return on investment.”
This article is based in part on a presentation by Bleasdale and Robin Trotman, DO, FIDSA, at the 2019 HFMA Annual Conference.
Interviewed for this article:
Susan C. Bleasdale, MD, FIDSA, FACP, is medical director of infection prevention and control and antimicrobial stewardship at UI Health, Chicago ([email protected]).
