June 30, 2008

As Medicare prepares to stop reimbursing hospitals for certain hospital acquired conditions (HACs), IDSA and the Society for Healthcare Epidemiology of America (SHEA) continue to advocate a cautious approach that protects patient safety without resulting in unintended consequences.

As of Oct. 1, 2008, hospitals will not receive additional payment for several conditions if they were not present on admission. The conditions most relevant to infectious diseases physicians are catheter-associated urinary tract infections, vascular catheter-associated infections, and mediastinitis after coronary artery bypass graft surgery.

More recently, the Centers for Medicare and Medicaid Services (CMS) proposed adding additional conditions to the list., These include:

• Surgical site infections following total knee replacement, laparoscopic gastric bypass and gasteroenterosotomy, and varicose vein ligation and stripping
• Legionnaires’ disease
• Ventilator-associated pneumonia (VAP)
• Staphylococcus aureus septicemia
• Clostridium difficile-associated disease (CDAD)
• Methicillin-resistant Staphylococcus aureus (MRSA)

Although infection control advocates view these changes as well-intentioned, there is concern that even the best hospitals may not be able to eliminate these conditions entirely over the long term, even with complete adherence to evidence-based guidelines. As such, IDSA and SHEA are urging the agency to examine other markers, such as whether or not hospitals adhere to evidence-based process measures.

“There may be unintended consequences of designating HACs for non-payment that are not ‘reasonably preventable,’” wrote SHEA and IDSA in a letter to CMS Acting Administrator Kerry Weems. “We encourage CMS to look for these unintended consequences.”

For example, including Legionnaires’ disease as a HAC could lead many hospitals to invest substantial resources in unnecessarily screening and treating water supplies for this very infrequent nosocomial infection—resources that could be better spent on infection prevention.

Other problems with the new infections on CMS’s proposed list include a clear lack of diagnostic criteria for indentifying patients who have a condition (such as VAP) and the difficulty of ascertaining where the infection was acquired (such as CDAD).

Despite these concerns, advocates hope the changes will cause hospitals to invest more in infection control. And even with the new changes, ID physicians will still be reimbursed under the physician fee schedule, which means Medicare will continue to pay doctors for inpatient consultations and subsequent hospital visits related to the conditions on CMS’s list.

For the IDSA-SHEA comment letter, click here. Also see IDSA News, September 2007. Other quality improvement resources and tools are available on the IDSA website.

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