Mandatory reporting and pay for performance: health care infections in the limelight

AORN Journal,  April, 2008  by Kathleen Meehan Arias

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The CMS is moving from a pay-for-reporting system to one based on pay for performance. In August 2007, the CMS announced changes to the acute care hospital inpatient prospective payment system. For discharges occurring on or after October 1, 2008, Medicare no longer will pay a hospital for additional costs of certain preventable conditions that a patient acquires while in the hospital. Further, CMS has selected those conditions it deems to be "reasonably preventable" based on the existence of evidence-based guidelines for preventing their occurrence.

The CMS also has targeted eight health conditions, including three HAIs (ie, catheter-associated urinary tract infections, vascular catheter-associated infections, mediastinitis after coronary artery bypass graft surgery). (15) When the Diagnosis Related Group code indicates that one of these conditions is secondary and the condition was not present on admission, the increased costs associated with the treatment of these conditions will not be covered by Medicare. (15) Hospitals also will not be permitted to bill patients for additional costs related to these infections.

WILL MANDATORY REPORTING AND PAY FOR PERFORMANCE PREVENT INFECTIONS?

Hospital infections have moved into the national limelight, and the focus of the health care industry now is on infection prevention. The question remains: will mandatory reporting and pay for performance prevent HAIs? Although public reporting and pay for performance have been debated extensively, little is known about the effects these measures have on health care quality. (16-21) Mandatory reporting and pay for performance are only two of the many strategies that can be used to improve the health care system. Implemented alone, these strategies likely will not improve the quality of health care or reduce infection rates. The debates about public reporting and pay for performance programs, however, have focused national attention on the problem of HAIs. This creates both a challenge and an opportunity. The challenge is present because not all HAIs are preventable. The opportunity exists because many HAIs are preventable, and it appears that a greater proportion of HAIs can be prevented than previously was estimated. (22)

The CDC's Study on the Efficacy of Nosocomial Infection Control, published in 1985, estimated that about one-third of HAIs could be prevented if a hospital had an effective infection-control program. (23) For many years, one-third was the generally accepted level of preventability. More recent studies, however, have demonstrated that a higher proportion of some infections, such as central line-related bloodstream infections and ventilator-associated pneumonia (VAP) can be prevented. (22)

SUCCESSFUL PROGRAMS

In the past decade many hospitals, professional associations, and performance improvement organizations have promoted HAI-prevention initiatives. For instance, the Pittsburgh Regional Healthcare Initiative, a consortium of health care facilities, insurers, employers, health care providers, corporate and civic leaders, and local health authorities, was able to reduce the incidence of central line-associated bloodstream infections by 68% during a four-year period. (24) Similarly in Michigan, the statewide Keystone Project, an evidence-based intervention to prevent catheter-related infections in hospitals, demonstrated a sustained reduction of up to 66% of central line-associated bloodstream infections during an 18-month period. (25)