Money talks: CMS continues bold move into infection prevention
'If hospitals have not been paying attention to infection control up 'til now – they will be'
By Gary Evans, Senior Managing Editor
In the latest move in its dramatically expanding oversight of health care associated infection (HAI) programs, the Centers for Medicare and Medicaid Services (CMS) is calling for hospitals to report central line associated bloodstream infections (CLABSIs) to ensure full reimbursement for care. With several infection-control initiatives underway, CMS is lining up its forces to use the considerable power of the purse to prevent health care associated infections (HAIs).
"Let's face it, by 2013 reimbursement will be impacted by infection outcomes in hospitals," says Connie Steed, RN, BSN, CIC, manager of infection control at the Greenville (SC) Hospital System. "CMS is going to be getting central line infection data beginning next year and then the year after some surgical site infection data. The plan is that eventually CMS will use those outcome rates [and other data] to impact hospital reimbursements. So if a hospital has not been paying attention to infection control up to now they will be. Especially if it affects their bottom line."
Under the conditions of a final CMS rule released July 30, 2010, the CLABSI reporting will be done through the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN). Once reported, CMS will eventually release the information to consumers on its Hospital Compare website. The CMS will phase in the requirements beginning with reporting CLABSIs on Jan. 1, 2011. In addition to bloodstream infections, CMS plans include collecting data related to preventing surgical site infections and beefing up infection control in ambulatory and long-term care.
Controversial visionary takes CMS helm
Emboldened under the leadership of new administrator and longtime health care quality and transparency advocate Don Berwick, MD, CMS is poised for a continuing escalation of fiscal pressure on hospitals to adopt quality measures and best practices to reduce HAIs. In an interview prior to his CMS appointment in July, Berwick described himself as something of an "extremist" on health care transparency. "Being aware of variation in infection rates is going to stir the 'super-egos' of the system quite a bit and I hope the public gets a bit outraged and mobilized as voters," he said. "[They should] ask why we pay systems the amount of money we are and not have them adopt the best practices."1
In his first speech as CMS director on Sept. 14, 2010, Berwick called for "a major and immediate reduction in medical injuries to American patients in hospitals. . . . I am not in favor of a health care system in which patients and families roll dice on the quality of the care they get depending on where they happen to go. . . . [CMS] will establish and enforce accountabilities as a purchaser of care for over 100 million Americans, we in CMS have a duty to do that. We will help. We will encourage. And we will carefully watch."
The focus on the hospital environment follows dramatically increased CMS inspections and oversight of ambulatory care in the wake of a highly publicized outbreak of hepatitis C virus in Las Vegas in 2008-2009. The CMS also has stepped up infection prevention scrutiny of long-term care, ratcheting up oversight in part due to incidents like hepatitis B virus transmission among residents due to shared use of glucose monitoring equipment.
Indeed, if the growing CMS oversight of long-term care is any indicator, hospital infection preventionists (IPs) can expect to see CMS inspectors come in for less than cordial visits, an IP said recently in New Orleans at the annual meeting of Association for Professionals in Infection Control and Epidemiology (APIC).
"Those of us who have been working in long-term care a long time understand the power of the words that come from CMS," said Deb Patterson Burdsall, MSN, RN-BC, CIC, infection preventionist at Lutheran Life Communities in Arlington Heights, IL. "You are just learning it in acute care with 'never events' and non-payment. Those who hold the purse strings control a whole lot. The minute they start regulating, it becomes a whole new world."
Underscoring the point with a touch of macabre, Burdsall compared the CMS inspection process with a typical accreditation survey. "This is not the Joint Commission," she told APIC attendees. "This is not one of those, 'I think you should fix this.' This is: 'We are going to shut you down. We're going to take over your administration, and we are going to fine you $10,000 per day per occurrence for whatever happens.' These people can get pretty nasty and they have teeth."
A powerful ally
However, in sharp contrast to prior battles with the Occupational Safety and Health Administration over tuberculosis regulations, individual IPs and APIC are well aware that the CMS gives them a powerful ally. Moreover, established CDC-sanctioned reporting systems enforced by the CMS could bring a needed equity to the health care system. For example, Steed says the latest CMS move may level the proverbial playing field on reporting infections like CLABSIs.
"In this situation, I think it is a good thing to do for several reasons," she tells Hospital Infection Control & Prevention. "The whole country needs to have some level of accountability. Right now, only a partial number of states have public reporting laws."
With South Carolina being one of those, Steed has been making her data public and using the NHSN system since 2007. With other states having to come on board to meet CMS requirements, the result should be "a national data repository so that we will be able to look at and analyze trends about health care associated infections," she says.
Moreover, CMS regulations empower infection prevention programs and make administrators specifically accountable, Steed reminded IPs recently at the APIC conference.
The current CMS conditions-of-participation regarding infection prevention include this unequivocal language, she emphasized: "The CEO, the medical staff and director of nursing must ensure that the hospital-wide QA program and training programs address problems identified by the ICO [infection control officer] and be responsible for the implementation of successful corrective action plans in affected problem areas."
Reading the passage off to APIC attendees, Steed said, "I love this. It doesn't say 'can' or 'may' it says 'must.' I am telling you use this. Use this with all the confidence that you have."
Administrators are increasingly aware of the CMS interest in infection prevention, so IPs may find them particularly receptive to these issues, she notes.
A 'land shift' change
"Clearly, CMS has a major influence on organization leadership," adds Russell Olmsted, MPH, CIC, epidemiologist in Infection Prevention & Control Services at St. Joseph Mercy Health System in Ann Arbor, MI. "They are responding to reimbursement issues. So that trend certainly has been healthy the presence and awareness of CMS on 
the whole problem of health care associated infections. I think this is a 'land shift' change. It reflects an overall concern about HAIs from a number of groups probably most vocally by consumers. They are driving this issue and I think CMS is responding to that."
Still, there remains the issue of having the resources available to meet the increasing request for data. APIC advises IPs to make a business case for their programs, using tools available on its website to show the power of infection prevention.
"These external activities from entities like CMS and third-party payers help inform that business case," Olmsted says. "It can be used really to support [an argument] for: 'Here is what we have currently; here is what we can do. If we want to move prevention even further, this is what we are going to need.'"
In that regard, APIC supported the CMS regulatory action on CLABSIs as a continuing move toward transparency and accuracy in public reporting of a deadly infection. APIC estimates that 80,000 patients a year in the U.S. develop catheter-related BSIs, and about 30,000 die from them, accounting for roughly a third of the deaths that occur each year from HAIs. The average cost of care for a patient with this type of infection can exceed $30,000, costing the U.S. healthcare system more than $2 billion annually.
In particular, APIC applauded the CMS plan for the required use of the NHSN system, saying it represents a major advance toward replacing the reliance on administrative/coding data. Because NHSN data are collected in a standardized fashion, using standardized definitions, it provides consumers with the most accurate and reliable information about their healthcare facilities, APIC stressed.
"NHSN methodology really gives us a truer picture of reductions or changes in frequency of HAIs," says Olmsted, APIC president-elect. "The traditional kind of data that CMS is more used to tapping into is administrative or billing data. The problem with that data base is that it doesn't have the precision that a true NSHN methodology has. There are some signals we can gather from administrative data, but we still need [standardized infection rate reporting]."
Therefore, the NHSN is the best currently available method for establishing a scientifically meaningful reporting and monitoring system for HAIs, APIC argues. The CMS is not requiring that every IP replace the surveillance systems they are using, Olmsted emphasized.
"They may have other propriety systems they are using, but the good news is that most of the surveillance technologies have been working closely with NSHN to ensure there is [compatibility]," he says. "Basically if you are using a proprietary system of surveillance that [data] can easily be transmitted into NSHN. That makes a huge difference in balancing the burden and benefit of surveillance."
What about high-risk patients?
Still, Steed remains a bit wary of the growing expectation for zero infection rates as CMS and other regulators move aggressively into infection control. One of the unintended consequences could be efforts to reduce or deny care to patients prone to infections.
"I think there are going to be some patients that no matter what you do they might suffer from a health care associated infection because of their host conditions," she tells HIC. "We can't prevent them all."
Institutions willing to treat such high-risk patients should not be penalized by the CMS if they can't prevent all infections, she says.
"I am concerned this may lead to hospitals not taking care of high-risk patients," Steed says. "I've heard those conversations. The organizations that are really going to suffer are the ones that can't choose what patients they take care of. As long as [the CMS] goal and I think and hope it is is to improve quality, I don't think it is a bad thing. There is concern about how it might impact high-risk patients."
Reference
- Galewitz P. From The KHN Archives: Checking In With Dr. Donald Berwick. Kaiser Health News. April 19, 2010. Available on the web at: http://www.kaiserhealthnews.org/Checking-In-With/checking-in-with-berwick.aspx.
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