Medicare is preparing to penalize about 750 hospitals that have the highest rates of infections and patient injuries. The sanctions, estimated to total $330 million over a year, will kick in at a time when most infections and accidents in hospitals are on the decline, but still too common.
In 2012, 1 out of every 8 patients nationally suffered a potentially avoidable complication during a hospital stay, the government estimates. Even infections that are waning are not decreasing fast enough to meet targets set by federal health officials. Meanwhile, new strains of antibiotic-resistant bacteria are making infections much harder to cure.
Dr. Clifford McDonald, a senior adviser at the federal Centers for Disease Control and Prevention, says the worst performers "still have a lot of room to move in a positive direction."
Starting in October, a quarter of the nation's hospitals — those with the worst rates — will lose 1 percent of every Medicare payment for a year. In April, federal officials released a preliminary analysis of which hospitals would be assessed — they identified 761. When Medicare sets final penalties later this year, that list may change because the government will be looking at performance over a longer period than it used to calculate the draft penalties. (The full list of preliminary hospital scores is available here.)
The Hospital-Acquired Condition Reduction Program, created by the 2010 health law, is the third of the mandatory pay-for-performance programs established under federal health law. The first levies penalties against hospitals with high readmission rates, and the second awards bonuses or penalties based on two dozen quality measures. Both programs are in their second year.
Annual Penalties Add Up
When all three programs are in place this fall, hospitals will be at risk of losing up to 5.4 percent of their Medicare payments.
In the first year of the penalties for hospital-acquired conditions, Medicare will look at three measures. One is the frequency of bloodstream infections among patients who had catheters inserted into a vein to deliver antibiotics, nutrients, chemotherapy or other treatments.
The second measure is the rate of infections from catheters inserted into the bladder to drain urine. Finally, Medicare will examine a variety of avoidable health problems some patients experience in hospitals, including bedsores, hip fractures, blood clots and accidental lung punctures.
Over the next few years, Medicare will also factor in infections of surgical wounds and the rates of infection by one of two bacteria resistant to antibiotic treatments: Clostridium difficile, known as C. diff, and methicillin-resistant Staphylococcus aureus, known as MRSA.
"We want hospitals focused on patient safety and we want them laser-focused on eliminating patient harm," says Dr. Patrick Conway, chief medical officer of the Centers for Medicare & Medicaid Services.
Medicare's penalties are going to hit some types of hospitals harder than others. An analysis of the preliminary penalties conducted for Kaiser Health News by Dr. Ashish Jha, a professor at the Harvard School of Public Health, found that publicly owned hospitals and those that treat large portions of low-income patients are more likely to be assessed penalties. So are hospitals that are large, urban or in the West or Northeast.
According to Medicare records, preliminary penalties were assigned to more than a third of the hospitals in Alaska, Colorado, Connecticut, the District of Columbia, Nevada, Oregon, Utah, Wisconsin and Wyoming. The biggest impact may be on the nation's major teaching hospitals: 54 percent were marked for preliminary penalties, Jha found.
"Hospitals that have been working hard to reduce infections may end up in the penalty box," says Nancy Foster, vice president for quality and public safety at the American Hospital Association.
The government takes into account the size of hospital, the location the patient was treated and whether it is affiliated with a medical school when calculating infection rates. But the Association of American Medical Colleges and some experts question whether those measures are precise enough.
Missed Surgical Nick Triggers Nasty Infection
Medicare assigned a preliminary penalty to Northwestern Memorial Hospital in Chicago, for instance, but Dr. Gary Noskin, the chief medical officer, says hospitals that are more vigilant in catching problems end up looking worse unfairly. "If you don't look for the clot, you're never going to find it," he says.
It took, for example, five days for doctors to identify the infection Dorothea Handron picked up when a surgeon unknowingly pierced her bowel in 2009. By the time they operated on her again, she was so weakened that she was placed in a medically induced coma at Vidant Medical Center in Greenville, N.C.
Under the scores released by Medicare in April, Vidant was assigned a preliminary penalty. Joan Wynn, who is in charge of safety at Vidant, says the hospital has taken many steps to reduce complications. The prospect of penalties is "difficult when you know how much your performance is improved," Wynn says.
Among its improvements, Vidant has added patients to internal committees and now reveals on its website the total number of medication errors, infections, falls and bedsores that patients at the hospital experience.
Vidant also asked Handron, who happens to be a retired nursing professor, to tell her experience to the hospital's trustees and to make a video for the medical staff.
Handron continues to advise the hospital. "I know they're going in the very right direction," Handron says. "I would have absolutely zero concern about myself or a family member going to Vidant for anything now."
This new effort by Medicare is just the latest campaign to get hospitals to lower rates of injuries to patients. In 2008 Medicare started refusing to reimburse hospitals for the extra cost of treating patients who suffered complications that the hospital could have prevented. A subsequent study by Harvard researchers found no evidence that the change led to lower infection rates.
"With infections, we are moving in the right direction," says Lisa McGiffert, who directs the patient safety program at Consumers Union. "But I would not say we are anywhere near where we need to be."
STEVE INSKEEP, HOST:
It's MORNING EDITION from NPR News. I'm Steve Inskeep.
RENEE MONTAGNE, HOST:
And I'm Renee Montagne. Go into any hospital and come out sicker? It happens a lot. The government estimates that in 2012, 1 out of every 8 patients in the country suffered a potentially avoidable complication during a hospital stay. So as part of an ongoing effort to get hospitals to take better care of patients, Medicare is cracking down on what's known as hospital-acquired conditions, infections and complications that can be deadly. Jordan Rau from Kaiser Health News is here to tell us more. Good morning.
JORDAN RAU: Good morning.
MONTAGNE: What specifically is the government doing here? Who is it going after?
RAU: The government is going to penalize a quarter of the nation's hospitals that have the highest rates of infections and other complications. That's about 750 hospitals. And they're going to be the ones that have infections from catheters. They're also going to be looking at blood clots, tears during surgeries, falls that happen to patients in hospitals and use those in assessing which quarter of the hospitals do the worst in the nation. And all of this starts in October.
MONTAGNE: So is this an ongoing effort on the part of the government, these penalties?
RAU: These are going to continue every, single year. Now, the penalty will remain the same. Medicare is going to take away 1 percent of every, single payment that it makes to a hospital over the course of that year. But what they are going to be looking at can change every year. The year after this one, they're going to add in surgical site infections. After that, they're going to add in two really nasty types of antibiotic-resistant bacteria. So they can change that along the way, but the basic rule stays the same. And the bottom quarter of hospitals get penalized, even if their rates of infections and these things are dropping. If they're still doing worse than everyone else, they're going to lose this 1 percent. And that continues.
MONTAGNE: And Jordan, which hospitals are getting penalized?
RAU: Well, we don't know for sure yet because they haven't released the final figures. But they have released some preliminary penalties. Publicly owned hospitals are much more likely to get penalized. Large hospitals get penalized. Hospitals in the West and in the northeast parts of the country do very badly. Hospitals in cities do badly. And the hospitals that do the worst are the academic medical centers, the teaching hospitals. And over half of those hospitals would be penalized.
MONTAGNE: So of these hospitals that are being penalized, what is the common thread, if there is any?
RAU: This is actually a fairly controversial program because of that - because people aren't quite sure why infection rates and other mishaps are higher at those hospitals. Is it because those patients are sicker, and when the calculations are done they don't really take that into account? Or is it that these big hospitals are just not paying as much attention to patients - that they're, you know, letting things slide too much? And that is a major subject of debate. And hospitals feel - the industry feels that, in some ways, this a very unfair penalty because of that.
MONTAGNE: Well, these penalties - you're talking about percentages. But what do they add up to in terms of dollars?
RAU: Depends on the hospital. It depends on how much money you make from Medicare. It can be a few hundred-thousand dollars. For a big hospital, it can easily be over a million dollars.
MONTAGNE: You have talked to us before about other government efforts to get hospitals to take better care of patients. Tell us how this new effort fits in.
RAU: This is the third of the major pay-for-performance measures that were included in the health law. And now hospitals basically have 30 or 40 different things that they can mostly get penalized for but, in some cases, get bonuses. Those include readmission rates, includes mortality rates, includes a whole host of things. And added together, hospitals who do the best could get, you know, 1, 1.5 percent more for each payment. But the hospitals that do the worst are now at risk of losing as much as 5 percent - 5.5 percent. And that's real money.
MONTAGNE: But the idea, of course, is that patients won't be coming back so often. They will be healthier- that sort of thing. So is part of this an opportunity for the federal government to save money?
RAU: Well, the federal government will be saving money on some of this. But most of it is really focused on changing the way the payments work because up till a couple of years ago, if you were a hospital and, you know, you operated on the wrong side or they got an infection, you actually got paid extra to take care of your own mistake. Now they are trying to make this much more of a performance-based payment system so that the places that do well are encouraged to do well financially.
MONTAGNE: That was Jordan Rau from our partner Kaiser Health News. Thanks very much.
RAU: Thank you. Transcript provided by NPR, Copyright NPR.