Friday, September 21, 2007

Medicare Should Reconsider Its Approach to Improving Infection Control

By: Abhas Gupta
    Several weeks ago, Bush administration officials announced their plans to revise Medicare policy to no longer cover hospital-acquired infections. Although a laudable step by the Administration, I feel the policy is designed to score political points more than actually reduce nosocomial infection rates.

    The CDC estimates that every year, 1.7 million people develop nosocomial infections and almost 100,000 die from them. Having worked on the inpatient medicine floors of several hospitals now, I am struck by the disparities that exist in infection control practices between even affiliated hospitals. At one hospital, the attention to infection precautions borders on obsession--nurses repeatedly remind physicians and visitors to gown, de-gown, wash their hands, and disinfect their stethoscopes. However, the situation at an affiliate hospital is decidedly more lax. Caregivers and visitors frequently enter isolated rooms without the proper precautions and nurses reflexively insert Foley catheters on all of their patients. The cause of these startling differences is multi-factorial and may include arrogance or laziness of hospital staff, the lack of a rigorous infection control culture, infrequent screening on admission, and misaligned financial incentives (hospitals get paid for treatment, not prevention).

    The change in Medicare policy presumably addresses the misalignment of financial incentives in infection control. The central idea behind the policy is that hospital-acquired infections will no longer be reimbursed, so hospitals will need to reduce infection rates or lose money. Unfortunately, I do not believe that hospitals will react in this way, at least in the short term. Instead, I suspect that they will do what they have been doing with lost revenue from the uninsured--shift costs by simply pricing their expected losses into private insurance billing.

    I feel a more constructive policy change would incorporate at least the following elements:
    • Allocate resources to monitor infection rates - the public should be able to monitor hospital rates to a) ensure that value is being generating from their monies spent, b) identify and address poor-performers, and c) create an avenue for patient and insurance provider pressure. Addendum: some twenty-two states have already introduced such legislation

    • Provide appropriate financial incentives - this is hands-down the best thing we can do to address infection rates. Organizations respond better to incentives than deterrents, and we--the public--are willing to spend more to save lives. If a framework is already in place for monitoring infection rates, we can implement "pay for performance" type incentives. For example, a hospital that decreases its infection rate by 10% from one year to the next would receive a medicare bonus. This amount should be substantial enough to create a market for outside consultants that come in and introduce rigorous infection control practices

    • Recognize differences in patient complexity - tertiary institutions can be expected to have higher rates than primary care centers. Therefore, tertiary centers should not be penalized disproportionately, nor should primary care centers be additionally compensated.

    • Allocate resources for all parties in the care cycle - eradication of nosocomial infections will require cooperation from (and funding for) nursing homes, rehabilitation centers, ambulatory services, etc.

    • Support a forum for sharing best-practices - the VAMC Pittsburgh has aggressively addressed hospital infection rates and has subsequently generated some impressive results in the past few years. All hospitals should benefit from their findings.
    Addendum: Instituting a performance-based bonus would be expensive, but create tremendous value per dollar spent. Also, there would be significant savings recouped from decreased hospital stays. I haven't been able to find a specific number, but if the incidence of nosocomial infections is 1.7 million patients annually, the cost of poor infection control must surely be in the tens of billions.

    1 comment:

    MAC said...

    I do not defend Bush's action, but remember that economics is the allocation of scarce resources. Is the funding formerly used for this project being shifted to one that brings more healthcare benefits? If that is the case, then although it will have an adverse impact on nosocomial infection rates, it is the economic choice