Medicare's Nonpayment Policy May Be Working

Diana Phillips

January 08, 2015

Medicare's policy not to pay for treating hospital-acquired conditions (HACs) appears to be most effective in reducing avoidable events for which standardized prevention evidence is available.

Unit-level rates of central-line associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) decreased significantly since the 2008 implementation of the Medicare initiative, according to a study of adult nursing units from 1381 US hospitals. The findings were reported in an article published online January 5 in JAMA Internal Medicine.

Using outcome data reported to the National Database of Nursing Quality Indicators, Teresa M. Waters, PhD, from the Department of Preventive Medicine at the University of Tennessee Health Sciences Center in Memphis, and colleagues measured the association between the nonpayment policy and four of the eight "never-events" addressed by the HACs initiative: CLABSIs, CAUTIs, hospital-acquired pressure ulcers (HAPUs), and injurious inpatient falls.

For the analysis, the investigators combined the National Database of Nursing Quality Indicators data with American Hospital Association, Medicare Cost Report, and local market data to examine adjusted outcomes and developed multilevel models to evaluate the effect of the nonpayment policy on never events.

The results indicate that the financial penalties were associated with substantial changes in the infection outcomes but "had no effect on the trajectories of stage III/IV HAPUs and injurious falls," the authors report. Specifically, the nonpayment policy was associated with an 11% reduction in the rate of change in CLABSIs and a 10% reduction in the rate of change in CAUTIs. The authors note that the associations remained significant after adjusting for unit-, hospital-, and market-level factors.

In considering the fitted trajectories of HACs over time from the base model, "Stage III/IV HAPUs and inpatient injurious falls declined somewhat steadily during the study period (July 1, 2006, to December 31, 2010), with the policy introduction having little, if any, effect on their downward trend," the authors observe. "Slight upward, but statistically insignificant, trends occurred in CLABSIs and CAUTIs during the first 9 months of [the] study period...[and] followed significant downward trends in the subsequent 27 months," the authors state.

The findings seem to contradict those of an earlier study, which found no association between the nonpayment rule change and CLABSI or CAUTI rates. The discrepancy may be a function of the larger sample size, broader geographical representation, and inclusion of more nonteaching hospitals in the current study, the authors suggest.

Prevention guidelines exist for all measures included in the 2008 rule, but "not all were supported by the same level of scientific evidence," the authors note. Although evidence-based procedures for preventing CLABSIs and CAUTIs were "relatively well developed" by 2008, "[i]t is arguable that the evidence base supporting the prevention of injurious falls and HAPUs was less robust," they state.

Prevention of the infection events "may also be more amenable to standardization, facilitating effective dissemination and implementation of process improvements," the authors hypothesize. "In addition, these infectious are more likely to occur in [intensive care units] or specialized units where a limited set of patients are under the vigilant eye of a focused medical team and infection control departments." The need for ongoing and comprehensive prevention in patients at risks for HAPUs or falls "makes standardization far more challenging," they state.

The findings are relevant to other Centers for Medicare & Medicaid Services initiatives related to HACs, including public reporting of health outcomes and the assessment of hospital penalties under the Hospital-Acquired Condition Reduction Program, which is slated for implementation in fiscal year 2015. Both initiatives incentivize hospitals to improve their performance, the authors note. "Our results suggest that initiatives focusing on areas with a well-developed evidence base for prevention and areas amenable to standardization are more likely to be successful in driving improvement."

In this regard, policymakers selecting new areas for quality improvement focus "may wish to invest directly in the science, rather than rely on incentives to drive scientific development, when a strong evidence base and standardization are lacking," the authors conclude.

In an accompanying commentary, Craig A. Umscheid, MD, and Patrick J. Brennan, MD, from the Department of Medicine at the University of Pennsylvania, Philadelphia, note that the implementation of evidence into practice to reduce falls and pressure ulcers is "arguably the more typical type of challenge encountered in our health care system." Such challenges require multidisciplinary, patient-centered collaboration across the entire spectrum of care, and as such, they "may be immune to financial incentives narrowly focused on individual clinical outcomes," they write.

Rather than calling on policy makers to focus incentives "on clinical outcome metrics with robust evidence available to guide improvement efforts," the editorialists "would like to instead call on policy makers, such as the Centers for Medicare & Medicaid Services and the Joint Commission, to recalibrate their incentive targets away from those solely focused on narrow clinical outcomes and more toward structures that promote the implementation of evidence-based care in real-world settings." Such structure-focused incentives, they contend, "will successfully bridge the knowing-doing gap for the more complex clinical challenges before us."

The authors and editorialists have disclosed no relevant financial relationships.

JAMA Intern Med. Published online January 5, 2015. Article full text, Editorial full text

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