Before the Shoe Drops: Anesthesiologists Can Help Hospitals Prevent Certain Hospital-Acquired Infections
Anesthesiologists increasingly point to their role in driving down the rate of surgical site and other hospital-acquired infections (HAIs). Not only does anesthesiologists’ and nurse anesthetists’ compliance with the relevant quality measures help the hospitals’ quality scores and satisfy PQRS requirements, preventing HAIs is good for patients and saves on health care system costs.
Compliance with quality standards and improvement upon current scores are often elements in negotiations with hospitals, ambulatory surgical centers and, more and more, third-party payers. When it comes to including performance bonuses in contracts, the principle is sound, but the dollar value has been elusive. A new study published in the online edition of JAMA Internal Medicine on September 2, 2013, Health Care-Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care System by Zimlichman et al. at the Brigham & Women’s Hospital in Boston, analyzed the literature and available databases to determine the costs of the five most common, expensive, preventable and well-tracked HAIs in hospitalized patients. Three of these HAIs are subject to preventive measures commonly performed by anesthesiologists: surgical site infections (SSIs), central line-associated bloodstream infections (CLABSIs) and ventilator-associated pneumonia (VAP).
The table below shows the estimated costs and incremental inpatient days attributable to the five infections. The first three HAIs are addressed by PQRS measures that apply to anesthesiologists. MRSA SSIs and CLABSIs are broken out because of their particularly high treatment costs. The cost and length of stay (LOS) data are point estimates from 26 “reasonably robust” studies, generated using Monte Carlo simulation techniques that also produced 95 percent confidence intervals not shown here, adjusted for inflation to 2012 values. The incidence estimates come from the most recent available National Healthcare Safety Network databases (2008 and 2009). They exclude patients in pediatric, neonatal and long-term acute care settings and thus may underreport the total incidence of the HAIs studied.
Thus these five HAIs, at least half of which are preventable, are an annual $9.8 billion drain on the US healthcare system. Nearly half a million adult patients experience one of the infections yearly, with average additional time spent in the hospital ranging from 3.3 to 23.0 days.
If so much of the illness and spending is preventable, why does it continue? Clearly the rate of specific HAIs has dropped over the last decade. Yet there is still a potential cost savings of $5.0–$5.5 billion annually that hospitals could achieve, according to Zimlichman.
Until recently, under Medicare’s traditional fee-for-service payment system, complications including HAIs were reclassified to a higher DRG payment. In other words, hospitals were perversely paid more for failing to prevent HAIs than for avoiding them. Beginning in 2006, under the 2005 Deficit Reduction Act, Medicare stopped paying for certain preventable hospital-acquired conditions (HACs) including some SSIs, CLABSIs and catheter-associated urinary tract infections. CMS expects the total savings from the withholding of payment for the hospital-acquired infections in question to range from just $26 million in 2014 to $36 million in 2018, according to the final Inpatient Prospective Payment Rule for 2014—amounts so negligible that Cheryl Clark, writing in the September 5, 2013 issue of Health Leaders Media (“Financial Incentives for Preventing HAIs Don’t Add Up to Much”) calls them “chump change.”
Other pejoratives with which Clark dismisses federal incentives to reduce the rate of HACs are:
- “Mickey Mouse” (the states, which administer the Medicaid program, were only required to adopt HAC non-payment rules beginning in 2011; the estimated savings for 2011–2015 is $35 million);
- “Chicken Feed” (beginning on October 1, 2014, hospitals with relatively higher rates of CLABSI will forfeit a small withhold as part of the value-based purchasing incentive program), and
- “Peanuts” (also beginning on October 1st, the Affordable Care Act’s HAC penalty goes into effect. Hospitals whose rates of HACs are in the top quartile this year will receive a one-percent DRG payment cut in 2015—potentially a significant dollar amount, but not enough to motivate hsopitals to take action in 2013, according to Clark.).
As Clark observes, the Zimlichman study “was an effort to brace hospital leaders against the shock they'll get when payment reforms are much more robust than they are today.” This is where anesthesiologists come in. Use the Zimlichman study, and apply its methodology to available data for your own hospital. Do your quality data show, by way of example, two fewer cases of SSIs in 2013 than in 2012 (and is the decrease at least arguably part of a trend)? If the Zimlichman numbers are representative, and if you can show good compliance with the prophylactic antibiotic and normothermia quality measures, you may have saved the hospital more than $41,500.
Do you need the hospital to make an investment in technology or clinical staff that will help you control the rate of HAIs? The study points you in the right direction.
If the hospital administration is willing to look a few years ahead, it will probably see an ever-growing set of financial penalties associated with potentially avoidable complications—on the part of the private payers as well as Medicare and Medicaid. We have written often of the need for anesthesiologists to become their facilities’ true partners. SSIs, the prevention of which is within anesthesiologists’ control as much as any other doctors’, generate the largest portion of HAI-related costs nationally, and less progress has been made in preventing such infections than in other areas of health care. The opportunity is there, as you already know. The Zimlichman study provides the research and the data to help you take advantage of the window while it is still open.