In 2009, the U.S. Department of Health and Human Services unveiled its five-year “Action Plan to Prevent Healthcare-Associated Infections (HAIs).” Two of the primary goals of the plan call for hospitals to cut invasive methicillin-resistant Staphylococcus aureus (MRSA) infections in half and Clostridium difficile infections by 30% before 2014.
Achieving these targets will significantly improve healthcare outcomes and reduce costs for all stakeholders but also will require substantive changes in how care is delivered. For example, most institutions still do not have electronic-surveillance systems to track, target, and prevent infections, let alone address reporting requirements effectively. Like most improvements in care, infection prevention requires investment — which can be difficult to obtain in our increasingly cost-constrained delivery system.
Value-based purchasing (VBP) can provide hospitals the opportunity to obtain the resources needed to implement and sustain more robust infection prevention and control programs. The core tenet of VBP, according to the Centers for Medicare and Medicaid Services (CMS), is to “revamp how care and services are paid for, moving increasingly toward rewarding better value, outcomes, and innovations instead of merely volume.” VBP is designed to link payment to quality practices and outcomes. Financial incentives will be awarded to hospitals based on performance data collection. High-performing hospitals will receive a larger incentive than low-performing hospitals.
Consistent with the recommendations of the HAI Action Plan, Congress designed VBP with the goal of reducing the incidence of these largely preventable infections. Addressing HAIs through VBP encourages the type of culture change that will not only lead to reduction in preventable infections but also in improved patient safety at a systemic level. The proposed VBP framework that CMS released in January 2011 includes a number of preventable occurrences such as falls and foreign objects left in patients following surgery. Despite legislative requirements to include all elements of the HAI Action Plan, MRSA and C diff, among the most costly and deadly infections, have not yet specifically been included in CMS’ current VBP proposal.
Today, hospitals are reeling from unfavorable economics, including reductions in diagnosis-related group reimbursements. A recent Agency for Healthcare Research and Quality study estimated that an HAI adds 19 days to a hospital stay and costs $43,000.1 As of 2008, Medicaid and Medicare no longer pay for some conditions acquired in the hospital, and some insurers are following suit, which means hospitals will bear the direct cost.
VBP was designed to reward hospitals that consistently demonstrate positive outcomes, including reductions in the incidence of HAIs. VBP must provide incentives for hospitals to adopt strategies and processes that tackle all HAIs. By rewarding quality and outcomes, VBP will help to transform the delivery of care, offering a financial boost to critical programs like infection prevention and control. Providing progress-based incentives is critical for resource-starved hospitals that cannot afford state-of-the-art screening protocols, adequate staff resources, or technology that can reduce infection risk.
VBP also encourages system-wide changes that improve the process of care. For example, electronic surveillance and data collection, while indisputably an enabler of improved care and greater efficiency, is often seen as too costly. VBP gives institutions additional incentive to invest in electronic surveillance in order to quantify improvement and qualify for additional payment.
Allegheny General Hospital in Pittsburgh, PA, succeeded in reducing central-line-associated bloodstream infections by 90%, with an average savings of $14,572 per infection.2 As a result, the hospital received $2.1 million in incentive payments.3 The facility invested a portion of these additional resources in hiring additional respiratory therapists, achieving an 82% reduction in cases of ventilator-associated pneumonias (VAP).2 Thus, one financial reward initiated a cycle of excellence which helped set this hospital on the path to some of the lowest rates of HAIs in the United States.
VBP alone cannot reduce the health burden and economic impact of HAIs. Robust infection-prevention-and-control programs are primarily the result of strong cultures of patient safety. By focusing executive attention and aligning incentives for improved care, however, VBP may accelerate positive culture change including consistent application of infection-prevention measures.
During the mid-2000s, MRSA cases were rising at Pitt County Memorial Hospital (PCMH), in Greenville, NC, as in many U.S. hospitals. PCMH devised and implemented an infection-prevention-and-control program to reduce VAP caused by MRSA. As part of this effort, the hospital tested all admissions to the surgical intensive-care unit for MRSA using an assay based on real-time polymerase-chain-reaction technology. Shortly afterward, active surveillance for MRSA was extended to all hospital admissions.
Over the next year, MRSA-related HAIs fell significantly, including VAP rates which decreased by 68%. Today, healthcare-associated MRSA infections are rare at PCMH. The Veterans’ Health Administration recently recognized PCMH as a leading-practice hospital in HAI prevention and has blueprinted the hospital’s infection-prevention strategy on its website.4
By rewarding institutions for improving outcomes, VBP encourages and supports a virtuous cycle of continuous improvement. Hospitals that invest the accruing initial financial incentives into more-robust infection-prevention programs and technologies will continue to be rewarded.
References
- Lucado J, Paez K, Andrews R, Steiner C. Adult hospital stays with infections due to medical care, 2007. Statistical brief No. 94. Agency for Healthcare Research and Quality. Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb94.pdf. Published August 2010. Accessed February 14, 2011.
- Murphy D, Whiting J. Dispelling the myths: The true cost of healthcare-associated infections. Association for Professionals in Infection Control and Epidemiology. Washington, DC. http://www.premierinc.com/safety/topics/guidelines/downloads/09-hai-whitepaper.pdf. Published February 2007. Accessed February 14, 2011.
- The Committee on Energy and Commerce. Public reporting of hospital-acquired infection rates: Empowering consumers, saving lives. http://republicans.energycommerce.house.gov/108/Hearings/03292006hearing1821/Shannon2791.htm. Published March 29, 2006. Accessed February 14, 2011.
- University Health Systems of Eastern Carolina. Study shows universal surveillance for MRSA significantly decrease health care-associated infections at Pitt County Memorial Hospital. http://www.uhseast.com/uhseast/newsroomdetail.aspx?id=9008. Published July 13, 2010. Accessed February 14, 2011.
Kathy Warye
, is vice president of infection prevention at BD. Prior to joining BD, she served as the CEO of the Association for Professionals in Infection Control and Epidemiology (APIC).
