Latest Hospital Injury Penalties Include Crackdown On Antibiotic Resistant Germs

Reprinted from KHN / Kaiser Health News

By Jordan Rau December 21, 2016

http://www.khn.org/

The federal government has cut payments to 769 hospitals with high rates of patient injuries, for the first time counting the spread of antibiotic-resistant germs in assessing penalties.

The punishments come in the third year of Medicare penalties for hospitals with patients most frequently suffering from potentially avoidable complications, including various types of infections, blood clots, bed sores and falls. This year the government also examined the prevalence of two types of bacteria impervious to drugs.

Based on rates of all these complications, the hospitals identified by federal officials this week will lose 1 percent of all Medicare payments for a year — with that time frame beginning this past October.  While the government did not release the dollar amount of the penalties, they will exceed a million dollars for many larger hospitals. In total, hospitals will lose about $430 million, 18 percent more than they lost last year, according to an estimate from the Association of American Medical Colleges.

The reductions apply not only to patient stays but also will reduce the amount of money hospitals get to teach medical residents and care for low-income people.

Forty percent of the hospitals penalized this year escaped punishment in the first two years of the program, a Kaiser Health News analysis shows. Those 306 hospitals include the University of Miami Hospital in Florida, Cambridge Health Alliance in Massachusetts, the University of Michigan Health System in Ann Arbor and Mount Sinai Hospital in New York City.

Nationally, hospital-acquired conditions declined by 21 percent between 2010 and 2015, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The biggest reductions were for bad reactions to medicines, catheter infections and post-surgical blood clots.

Still, hospital harm remains a threat. AHRQ estimates there were 3.8 million hospital injuries last year, which translates to 115 injuries during every 1,000 patient hospital stays during that period.

Each year, at least 2 million people become infected with bacteria that are resistant to antibiotics, including nearly a quarter million cases in hospitals. The Centers for Disease Control and Prevention estimates 23,000 people die from them.

Infection experts fear that soon patients may face new strains of germs that are resistant to all existing antibiotics. Between 20 and 50 percent of all antibiotics prescribed in hospitals are either not needed or inappropriate, studies have found. Their proliferation — inside the hospital, in doctor’s prescriptions and in farm animals sold for food — have hastened new strains of bacteria that are resistant to many drugs.

One resistant bacteria that Medicare included into its formula for determining financial penalties for hospitals is methicillin-resistant Staphylococcus aureus, or MRSA, which can cause pneumonia and bloodstream and skin infections. MRSA is prevalent outside of hospitals and sometimes people with it show no signs of disease. But these people can bring the germ into a hospital, where it can be spread by health care providers and be especially dangerous for older or sick patients whose immune system cannot fight the infection.

Hospitals have had some success in reducing MRSA infections, which dropped by 13 percent between 2011 and 2014, according to the CDC. AHRQ estimates there were 6,300 cases in hospitals last year.

The second bacteria measured for the penalties is Clostridium difficile, known as C. diff, a germ that can multiply in the gut and colon when patients take some antibiotics to kill off other germs. It can also spread through contaminated surfaces or hands.

While it can be treated by antibiotics, C. diff can also become so serious that some patients need to have part of their intestines surgically removed. C. diff can cause diarrhea and can be deadly for the elderly and other vulnerable patients.

C. diff has challenged infection control efforts. While hospital infections dropped 8 percent from 2008 to 2014, there was a “significant increase” in C. diff that final year, the CDC says. AHRQ estimated there were 100,000 hospital cases last year.

“The reality is we don’t know how to prevent all these infections,” said Dr. Louise Dembry, a professor at the Yale School of Medicine and president of the Society for Healthcare Epidemiology of America.

The Hospital-Acquired Condition Reduction Program also factors in rates of infections from hysterectomies, colon surgeries, urinary tract catheters and central line tubs. Those infections carry the most weight in determining penalties, but the formula also takes into account the frequency of bed sores, hip fractures, blood clots and four other complications.

Specialized hospitals, such as those that treat psychiatric patients, veterans and children, are exempted from the penalties, as are hospitals with the “critical access” designation for being the only provider in an area. Of the remaining hospitals, the Affordable Care Act requires that Medicare penalize the 25 percent that perform the worst on these measures, even if they have reduced infection rates from previous years.

That inflexible quota is one objection the hospital industry has with the penalties. In addition, many hospitals complain that they are penalized because of their vigilance in detecting infections, even ones that do not cause any symptoms in patients. Academic medical centers in particular have been frequently punished.

“The HAC penalty payment program is regarded as rather arbitrary, so other than people getting upset when they incur a penalty, it is not in and of itself changing behavior,” said Nancy Foster, vice president for quality and patient safety at the American Hospital Association.

Federal records show that 347 hospitals penalized last year will not have payments reduced because their performance was better than others. Those include Harbor-UCLA Medical Center in Los Angeles, the Johns Hopkins Hospital in Baltimore and the University of Tennessee Medical Center in Knoxville.

Over the lifetime of the penalty program, 241 hospitals have been punished in all three years, including the Cleveland Clinic; Intermountain Medical Center in Murray, Utah; Ronald Reagan UCLA Medical Center in Los Angeles; Grady Memorial Hospital in Atlanta; Northwestern Memorial Hospital in Chicago; and Brigham & Women’s Hospital in Boston.

The penalties come as the Centers for Medicare & Medicaid Services also launches new requirements for hospitals to ensure that the use of antibiotics is limited to cases where they are necessary and be circumspect in determining which of the drugs are most likely to work for a given infection. Hospitals will have to establish these antibiotic stewardship programs as a condition of receiving Medicare funding under a regulation the government drafted last summer.

Lisa McGiffert, who directs Consumers Union’s Safe Patient Project, said that as a result of Medicare’s penalties and other efforts, “more hospitals are thinking more about appropriate use of antibiotics.” However, she said, “I think most hospitals do not have effective antibiotic stewardship programs yet.”

Many Well-Known Hospitals Fail To Score 5 Stars In Medicare’s New Ratings

The federal government released its first overall hospital quality rating on Wednesday, slapping average or below average scores on many of the nation’s best-known hospitals while awarding top scores to dozens of unheralded ones.

By Jordan Rau / July 27, 2016

The Centers for Medicare & Medicaid Services rated 3,617 hospitals on a one- to five-star scale, angering the hospital industry, which has been pressing the Obama administration and Congress to block the ratings. Hospitals argue the ratings will make places that treat the toughest cases look bad, but Medicare has held firm, saying that consumers need a simple way to objectively gauge quality.

Just 102 hospitals received the top rating of five stars, and few are those considered as the nation’s best by private ratings sources such as U.S. News & World Report or viewed as the most elite within the medical profession.

Medicare awarded five stars to relatively obscure hospitals and at least 40 hospitals that specialize in just a few types of surgery, such as knee replacements. There were more five-star hospitals in Lincoln, Neb., and La Jolla, Calif., than in New York City or Boston. Memorial Hermann Hospital System in Houston and Mayo Clinic in Rochester, Minn., were two of the only nationally known hospitals getting five stars.

Medicare awarded the lowest rating of one star to 129 hospitals. Five hospitals in Washington, D.C., received just one star, including George Washington University Hospital and MedStar Georgetown University Hospital, both of which teach medical residents. Nine hospitals in Brooklyn, four hospitals in Las Vegas and three hospitals in Miami received only one star.

Some premiere medical centers received the second highest rating of four stars, including Stanford Health Care in California, Massachusetts General Hospital in Boston, Duke University Hospital in Durham, N.C., New York-Presbyterian Hospital and NYU Langone Medical Center in Manhattan, the Cleveland Clinic in Ohio, and Penn Presbyterian Medical Center in Philadelphia. 

In total, 927 hospitals received four stars.

Medicare gave its below average score of two-star ratings to 707 hospitals. They included the University of Virginia Medical Center in Charlottesville, Beth Israel Medical Center in Manhattan, North Shore University Hospital (now known as Northwell Health) in Manhasset, N.Y., Barnes-Jewish Hospital in St. Louis, Tufts Medical Center in Boston and MedStar Washington Hospital Center in D.C. Geisinger Medical Center in Danville, Pa., which is a favorite example for national health policy experts of a quality hospital, also received two stars.

Hospital Stars

Medicare has released for the first time star ratings for more than 3,600 hospitals around the country. The government says the ratings, which award between one and five stars to each hospital, will be useful to consumers trying to evaluate quality. More than 100 facilities received five stars, the highest rating, while 129 got only one star.

Nearly half the hospitals — 1,752 — received an average rating of three stars. Another 1,042 hospitals were not rated, including all hospitals in Maryland.

Medicare based the star ratings on 64 individual measures that are published on its Hospital Compare website, including death and infection rates and patient reviews. Medicare noted that specialized and “cutting-edge care,” such as the latest techniques to battle cancer, are not reflected in the ratings.

Dr. Kate Goodrich, who oversees Medicare’s quality ratings, said in a statement that it has been using the same type of rating system for other medical facilities, such as nursing homes and dialysis centers, and found them useful to consumers and patients. Those ratings have shown, she said, “that publicly available data drives improvement, better reporting, and more open access to quality information for our Medicare beneficiaries.”

In a statement, Rick Pollack, president of the American Hospital Association, called the new ratings confusing for patients and families. “Health care consumers making critical decisions about their care cannot be expected to rely on a rating system that raises far more questions than answers,” he said. “We are especially troubled that the current ratings scheme unfairly penalizes teaching hospitals and those serving higher numbers of the poor.”

A sizable proportion of the nation’s major academic medical centers, which train doctors, scored poorly, according to a Kaiser Health News analysis. Out of 288 hospitals that teach significant numbers of residents, six in 10 received below-average scores, the analysis found. Teaching hospitals comprised one-third of the facilities receiving one-star. A number were in high poverty areas, including two in Newark, N.J., and three in Detroit.

“Hospitals cannot be rated like movies,” Dr. Darrell Kirch, president of the Association of American Medical Colleges, said in a statement. “We are extremely concerned about the potential consequences for patients that could result from portraying an overly simplistic picture of hospital quality with a star rating system that combines many complex factors and ignores the socio-demographic factors that have a real impact on health.”




TAGS: CMS, Hospitals

jrau@kff.org | @JordanRau