Bottom-tier hospitals got better at infection control, but still hit with 1% Medicare pay cuts

Hospitals with the worst rates patient infections have, on average, improved since 2018.

Despite moving the needle on healthcare-associated infections, however, there will always be losers under the CMS Hospital-Acquired Condition Reduction Program. The bottom 25%—749 hospitals—are subject to 1% Medicare payment cuts in fiscal 2022.

The Affordable Care Act established the penalty program as a way to put a spotlight on persistent patient safety problems. But the hospital industry questions whether the system is is fair, especially because healthcare-associated infections were declining prior to the COVID-19 pandemic.

"We've always found that it's misguided to have a program in which 25% of all hospitals must get a penalty based on performance, and it doesn't matter whether that individual hospital is improving," said Akin Demehin, director of policy at the American Hospital Association. "We don't think that's the optimal way to improve care."

A Modern Healthcare analysis shows that only 4.3% of hospitals that submit their infection data every year are consistent offenders that suffered penalties every year since 2018. These hospitals included University Medical Center of El Paso in Texas, Scripps Memorial Hospital Encinitas in California and Ascension St. Francis Hospital in Milwaukee. These hospitals didn't respond to requests for comment.

"That means most hospitals are really trying to improve," said Tejal Gandhi, chief safety and transformation officer at Press Ganey. "They may have a year where they didn't do well for whatever reason, but that there aren't a lot of hospitals consistently in the bottom 25%, I think, is a good thing."

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The CMS Hospital-Acquired Condition Reduction Program is based on two sets of infection measurements: Medicare claims data information from medical charts that hospital provide to the Centers for Disease Control and Prevention. The events that affect scores include central line-associated infections, surgical site infections, pressure ulcers, in-hospital falls, respiratory failure and sepsis after surgery. CMS rates hospitals relative to the national average and to their own past performance.

By design, the bottom quartile are subject to Medicare payment penalties even though the benchmark has changed over time as hospitals overall improve their infection rates. For example, the bar was slightly higher for 2022 than it was for 2018, meaning a hospital that earned the same score each year would have been penalized in 2022 but not in 2018.

In other words, hospitals prevented infections more effectively but, for some, it wasn't enough as compared to their peers to avoid penalties.

"It's not surprising that the bottom would be better, because the field as a whole pre-pandemic was focused on best practices around things like central-line infections and ways to embed processes into electronic health records," Gandhi said. The program itself deserves credit for pressuring hospitals to act, she said.

Change does not appear to be in the offing because it would require new legislation that the AHA isn't expecting any time soon.

CMS could update the infections used to evaluate hospitals, however. For instance, the National Quality Forum is looking at using data from electronic health records to capture a more comprehensive picture of patients' health, which can influence their vulnerability to infections. But updates to the healthcare-associated infections program appears to be at least a few years away.

CMS's decision to essentially ignore infections from 2020 because of the pandemic also raises questions about the program's usefulness. The penalties being assessed this year are based on data from July 2018 through December 2019 rather than the customary two-year period.

The pandemic introduced turmoil to hospital operations and to patient safety efforts. The usual routines for things such as keeping wounds clean or helping patients to the bathroom to prevent falls weren't possible because of strict COVID-19 worker exposure guidelines.

"Some of the things that we normally would have done, like going in a patient's room five times a day to check on the status of their central line, were not possible in the height of the pandemic," Gandhi said. "It takes time to figure out how are we going to change our process to try to prevent this infection when we can't do the things that we normally used to do."

CMS hasn't indicated what it will do about 2021. The pandemic continued to slam hospitals last year, but they also had more experience with the virus, more treatments available and a partially vaccinated population. But hospitals were still dealing with severe COVID-19 cases, mostly among unvaccinated patients, and higher volumes of sicker patients with other conditions who avoided hospitals in 2020.

Preliminary data point to increases in catheter-associated urinary tract infections, MRSA and ventilator-associated infections from 2019 to 2020, according to the CDC.

Patient safety advocates object to suppressing pandemic-era infections data. Instead, the argue CMS should scrutinize how hospitals performed during a period when patient safety became even more important.

Now isn't the time to back off from patient safety programs, said Leah Binder, president of safety and performance measurement nonprofit the Leapfrog Group. To fully address hospital safety, best practices from before the pandemic need to be continued, she said.

"Culture is critical," Binder said. Some hospitals didn't see more infections during the pandemic because their quality improvement processes are deeply embedded in their everyday practices. "Addressing patient safety means addressing the culture of safety within a hospital, not just attacking individual safety problems one by one," she said.