Medicare Cuts Payment to 774 Hospitals Over Patient Complications

A man in a hospital gown sits on a hospital bed

The federal government has penalized 774 hospitals for having the highest rates of patient infections or other potentially avoidable medical complications. Those hospitals, which include some of the nation’s marquee medical centers, will lose 1% of their Medicare payments over 12 months.

The penalties, based on patients who stayed in the hospitals anytime between mid-2017 and 2019, before the pandemic, are not related to covid-19. They were levied under a program created by the Affordable Care Act that uses the threat of losing Medicare money to motivate hospitals to protect patients from harm.

On any given day, one in every 31 hospital patients has an infection that was contracted during their stay, according to the Centers for Disease Control and Prevention. Infections and other complications can prolong hospital stays, complicate treatments and, in the worst instances, kill patients.

“Although significant progress has been made in preventing some healthcare-associated infection types, there is much more work to be done,” the CDC says.

Now in its seventh year, the Hospital-Acquired Condition Reduction Program has been greeted with disapproval and resignation by hospitals, which argue that penalties are meted out arbitrarily. Under the law, Medicare each year must punish the quarter of general care hospitals with the highest rates of patient safety issues. The government assesses the rates of infections, blood clots, sepsis cases, bedsores, hip fractures and other complications that occur in hospitals and might have been prevented. The total penalty amount is based on how much Medicare pays each hospital during the federal fiscal year — from last October through September.

Hospitals can be punished even if they have improved over past years — and some have. At times, the difference in infection and complication rates between the hospitals that get punished and those that escape punishment is negligible, but the requirement to penalize one-quarter of hospitals is unbending under the law. Akin Demehin, director of policy at the American Hospital Association, said the penalties were “a game of chance” based on “badly flawed” measures.

Some hospitals insist they received penalties because they were more thorough than others in finding and reporting infections and other complications to the federal Centers for Medicare & Medicaid Services and the CDC.

“The all-or-none penalty is unlike any other in Medicare’s programs,” said Dr. Karl Bilimoria, vice president for quality at Northwestern Medicine, whose flagship Northwestern Memorial Hospital in Chicago was penalized this year. He said Northwestern takes the penalty seriously because of the amount of money at stake, “but, at the same time, we know that we will have some trouble with some of the measures because we do a really good job identifying” complications.

Other renowned hospitals penalized this year include Ronald Reagan UCLA Medical Center and Cedars-Sinai Medical Center in Los Angeles; UCSF Medical Center in San Francisco; Beth Israel Deaconess Medical Center and Tufts Medical Center in Boston; NewYork-Presbyterian Hospital in New York; UPMC Presbyterian Shadyside in Pittsburgh; and Vanderbilt University Medical Center in Nashville, Tennessee.

There were 2,430 hospitals not penalized because their patient complication rates were not among the top quarter. An additional 2,057 hospitals were automatically excluded from the program, either because they solely served children, veterans or psychiatric patients, or because they have special status as a “critical access hospital” for lack of nearby alternatives for people needing inpatient care.

The penalties were not distributed evenly across states, according to a KHN analysis of Medicare data that included all categories of hospitals. Half of Rhode Island’s hospitals were penalized, as were 30% of Nevada’s.

All of Delaware’s hospitals escaped punishment. Medicare excludes all Maryland hospitals from the program because it pays them through a different arrangement than in other states.

Over the course of the program, 1,978 hospitals have been penalized at least once, KHN’s analysis found. Of those, 1,360 hospitals have been punished multiple times and 77 hospitals have been penalized in all seven years, including UPMC Presbyterian Shadyside.

The Medicare Payment Advisory Commission, which reports to Congress, said in a 2019 report that “it is important to drive quality improvement by tying infection rates to payment.” But the commission criticized the program’s use of a “tournament” model comparing hospitals to one another. Instead, it recommended fixed targets that let hospitals know what is expected of them and that don’t artificially limit how many hospitals can succeed.

Although federal officials have altered other ACA-created penalty programs in response to hospital complaints and independent critiques — such as one focused on patient readmissions — they have not made substantial changes to this program because the key elements are embedded in the statute and would require a change by Congress.

Boston’s Beth Israel Deaconess said in a statement that “we employ a broad range of patient care quality efforts and use reports such as those from the Centers for Medicare & Medicaid Services to identify and address opportunities for improvement.”

UCSF Health said its hospital has made “significant improvements” since the period Medicare measured in assessing the penalty.

“UCSF Health believes that many of the measures listed in the report are meaningful to patients, and are also valid standards for health systems to improve upon,” the hospital-health system said in a statement to KHN. “Some of the categories, however, are not risk-adjusted, which results in misleading and inaccurate comparisons.”

Cedars-Sinai said the penalty program disproportionally punishes academic medical centers due to the “high acuity and complexity” of their patients, details that aren’t captured in the Medicare billing data.

“These claims data were not designed for this purpose and are typically not specific enough to reflect the nuances of complex clinical care,” the hospital said. “Cedars-Sinai continually tracks and monitors rates of complications and infections, and updates processes to improve the care we deliver to our patients.”

There’s (still) a fungus among us

https://mailchi.mp/2c6956b2ac0d/the-weekly-gist-january-29-2021?e=d1e747d2d8

Candida auris actively shed in the healthcare environment - Outbreak News  Today

Remember 2019, when the scariest “new” pathogen was Candida auris, a drug-resistant fungus that was creeping into hospitals and nursing homes, often proving fatal to elderly and immune-compromised patients who came in contact with it? C. auris proved difficult to eliminate from infected facilities, sometimes requiring drywall to be ripped out of patient rooms in order to fully decontaminate. 

With all of our attention focused on COVID-19, C. auris and other drug resistant bacteria and fungi have been making a resurgence, according to a recent New York Times report. In Los Angeles County alone, 250 facilities now report C. auris infection, up from just a handful before the pandemic.

Unlike COVID-19, these pathogens cling relentlessly to surfaces, so protocols allowing the reuse of protective equipment in order to conserve resources inadvertently provided a mechanism for these bugs to spread. 

Steroids used to treat COVID-19 patients suppress the immune system, making patients more vulnerable. According to one expert, the spread of these drug-resistant infections shows the danger of “seeing the world as a one-pathogen world”.

Providers have had a laser focus on preventing the aerosol spread of COVID—now is the time to double down on surface decontamination and infection mitigation procedures to make sure we don’t meet the end of the pandemic with the rise of other classes of “superbugs”.

Doctors Fear Bringing Coronavirus Home: ‘I Am Sort of a Pariah in My Family’

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One doctor dreamed he was surrounded by coughing patients. “Most physicians have never seen this level of angst and anxiety in their careers,” a veteran emergency room doctor said.

SEATTLE — After her shifts in the emergency room, one doctor in Utah strips naked on her porch and runs straight to a shower, trying not to contaminate her home. In Oregon, an emergency physician talks of how he was recently bent over a drunk teenager, stapling a head wound, when he realized with a sudden chill that the patient had a fever and a cough. A doctor in Washington State woke up one night not long ago with nightmares of being surrounded by coughing patients.

“Most physicians have never seen this level of angst and anxiety in their careers,” said Dr. Stephen Anderson, a 35-year veteran of emergency rooms in a suburb south of Seattle. “I am sort of a pariah in my family. I am dipping myself into the swamp every day.”

As the coronavirus expands around the country, doctors and nurses working in emergency rooms are suddenly wary of everyone walking in the door with a cough, forced to make quick, harrowing decisions to help save not only their patients’ lives, but their own.

The stress only grew on Sunday, when the American College of Emergency Physicians revealed that two emergency medicine doctors, in New Jersey and Washington State, were hospitalized in critical condition as a result of the coronavirus. Though the virus is spreading in the community and there was no way of ascertaining whether they were exposed at work or somewhere else, the two cases prompted urgent new questions among doctors about how many precautions are enough.

“Now that we see front-line providers that are on ventilators, it is really driving it home,” Dr. Anderson said.

Doctors, nurses and other staff members in a variety of hospital departments face new uncertainty. In intensive care units, for example, health care providers must have extended exposure to people who have contracted the virus. But they know in advance of the risk they face.

In emergency departments, the danger comes from the unknown.

Patients arrive with symptoms but no diagnosis, and staff members must sometimes tend to urgent needs, such as gaping wounds, before they have time to screen a patient for Covid-19, the disease caused by the virus. At times, the protocols they must follow are changing every few hours.

“Many of us have trained for disasters, like Ebola and hurricanes,” said Dr. Adam Brown, the president of emergency medicine for Envision Healthcare, the largest provider of contract physicians to emergency rooms. “This is different because of the scale and scope of the disease.”

Add to that the shortage of protective gear and delays in testing, and health care workers fear they are flying blind.

Though the numbers are still low, Envision, which employs 11,000 emergency clinicians across the United States, has five times as many doctors under quarantine as it did a week ago, Dr. Brown said.

Several providers spoke on the condition of anonymity because their employers have told them not to talk to the news media.

The personal strain is cascading as the virus reaches new parts of the country. “Everybody feels the stress, but everybody is pulling together,” said Dr. K. Kay Moody, an emergency room doctor in Olympia, Wash., who runs a Facebook group with 22,000 emergency physicians. “That is what is keeping us OK.”

A few doctors said they were talking about bunking up in Airbnbs to create “dirty doc” living quarters to avoid endangering their children when they go home. Some are showing their partners where to find their passwords and insurance, should they end up in intensive care. Dr. Moody said she knew of at least one doctor whose former spouse was threatening to take their children away if the doctor went to work.

Many emergency physicians work as contractors, not hospital staff, so they will not necessarily be paid if they are quarantined. “As it stands, that is one of the most anxiety-provoking things,” Dr. Moody said, “on top of fear for your life.”

Nurses face similar challenges, though with less pay and support. An emergency nurse in Milwaukee said she bought her own goggles after hearing that protective gear was running low. A nurse at a rural hospital near Lake Tahoe in California said that the hospital was providing physicians with shower facilities as well as clean scrubs to wear, but that nurses had to wash their work clothes at home. She said that the physicians she worked with lobbied the hospital to provide clean scrubs for the nurses, but that the hospital concluded it would cost too much.

One doctor, who spoke on condition that the identity of the veterans hospital where she worked was not revealed, said the protocols have not kept up with the changing reality on the ground. When determining if a patient should get a separate room, she said, the emergency department still asks patients if they have been to high-risk countries, like China and Italy, even though community transmission of the virus has been well established.

Doctors have begun building plans for how they will ration supplies when there are more patients than their hospitals can handle. Emergency room doctors have experience sitting families down to advise discontinuing care because it would be futile. But in the United States, they are not used to making such calls based on resources alone.

Some said they were looking to Italy, where doctors on the front line have sometimes had to ration care in favor of younger patients, or those without other complicating conditions, who are more likely to benefit from it.

“If we get it all at once, we don’t have the resources, we don’t have the ventilators,” said Dr. William Jaquis, chair of the American College of Emergency Physicians.

Last week, Italian media reported that Bergamo, a city northeast of Milan, saw roughly 50 doctors test positive for the virus. In the region of Puglia in the south, local media reported that 76 employees had been quarantined after being exposed to patients who contracted Covid-19.

After the coronavirus broke out at a nursing facility near Seattle, Dr. Anderson sat with the leaders of his hospital, MultiCare Auburn Medical Center, to talk about how urgently they should prepare. Their hospital is ringed by nursing homes and other care facilities, and he rattled off those most at risk for fatal cases of the virus: males over 60, and those with cardiac and pulmonary problems. “I literally stopped what I was saying and realized that that was me,” he said.

He said his hospital was down to a two-day supply of surgical masks — he wears one per shift. “Those are supposed to be disposable,” he said. Now he must carefully remove and clean the mask each time he takes it off and on. “That may sound just like a nuisance, but when you’re potentially touching something that has the virus that could kill you on it, and you’re doing it 25 times a shift, it’s kind of nerve-racking,” he said.

His wife has moved to their mountain cabin, and they have given up on their retirement cruise in Europe. “I haven’t slept for longer than three hours in the past two weeks,” he said.

In the early hours of Monday morning, he could not sleep. More than 200 emails had come into his inbox since he went to bed, including news that three other health care providers had been admitted to a hospital overnight, he said.

But he plans to be at his next shift nonetheless.

“I have been doing this for 35 years,” he said, “and I’m not going to stop now.”

 

 

 

 

Seattle Children’s sues to block release of health records; top official resigns

https://www.beckershospitalreview.com/infection-control/seattle-children-s-sues-to-block-release-of-health-records-top-official-resigns.html?utm_medium=email

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Seattle Children’s Hospital has filed a lawsuit to block the release of health department records regarding mold at its facility, according to court documents cited by King 5. 

The hospital’s legal team filed an amended complaint in an attempt to block the release of state and county health records.

Documents previously released to the media through a public records request revealed a nearly 20-year history of Aspergillus mold in the air handling system of the hospital’s operating rooms.

Most recently, an infant at Seattle Children’s Hospital died Feb. 12 after she developed a mold-related infection acquired at the facility, the seventh mold-related death since 2001.

The health records sought by the media are “confidential and sensitive,” Adrian Urquhart Winder, attorney for Seattle Children’s, said, according to King 5. The attorney cited a state law that says records produced for quality improvement purposes cannot be publicly disclosed.

On Jan. 10, Mark Del Beccaro, MD, former CMO and senior vice president of Seattle Children’s Hospital, resigned, according to a hospital spokesperson. King 5 could not reach Dr. Del Beccaro for comment.

 

 

 

Study: Copper ICU Beds Mostly Untarnished by Bacteria

https://www.medpagetoday.com/criticalcare/infectioncontrol/83224?xid=nl_mpt_DHE_2019-11-09&eun=g885344d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%20Top%20Cat%20HeC%20%202019-11-09&utm_term=NL_Daily_DHE_dual-gmail-definition

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Converting from plastic surfaces could cut risk of HAIs, researchers argue.

Hospital beds with copper surfaces in an intensive care unit had significantly fewer bacteria than hospital beds with plastic surfaces, even after daily cleaning and disinfection, researchers found.

Active colony forming units per 100 cm2 on beds with copper rails, foot boards, and bed controls were less than 10% of those seen on conventional beds (median 42 vs 594), reported Michael Schmidt, PhD, of Medical University in South Carolina in Charleston, writing in Applied and Environmental Microbiology.

“The findings indicate that antimicrobial copper beds can assist infection control practitioners in their quest to keep healthcare surfaces hygienic between regular cleanings, thereby reducing the potential risk of transmitting bacteria associated with healthcare associated infections,” Schmidt said in a statement.

The authors explained that “metallic copper surfaces kill bacteria through a multi-modal mechanism through its ability to disrupt bacterial respiration, generate superoxide, and destroy genomic and plasmid DNA in situ.”

Studies have found that not only does environmental contamination play a role in transmitting pathogens responsible for healthcare-acquired infections, the investigators added, but copper-containing surfaces had reduced bacterial burdens.

Nevertheless, Schmidt noted, acute-care hospital beds on which all high-risk surfaces are copper have only recently become available.

“Based on the positive results of previous trials, we worked to get a fully encapsulated copper bed produced. We needed to convince manufacturers that the risk to undertake this effort was worthwhile,” he said.

This was a pragmatic cross-over study performed in a medical intensive care unit at a single medical center, which monitored the bacterial burden of control beds from April 2017 to July 2018, and interventional beds from April 2018 to March 2019 — noting a mixture of intervention and control beds from April to July 2018, as copper beds were introduced when a patient was discharged from a control bed.

Beds were thoroughly cleaned after patient discharge, and high-touch surfaces were routinely disinfected, as part of daily cleaning protocols, the authors said. Not surprisingly, they found that control beds accumulated higher concentrations of bacteria across all sampled areas, with the tops of the bed rails the most heavily soiled.

To put this into context, the authors noted that 89% of the samples collected from the control beds exceed the benchmark terminal cleaning and disinfection risk threshold compared to 9% from the copper beds, and 42% of copper beds were free of detectable bacteria.

In fact, the area with the heaviest bacterial burden on the copper bed was the internal, patient-facing surface of the foot board — though it was significantly lower than the comparative location on the control foot board, the authors noted.

One barrier to implementing this solution could be the cost of copper beds, but Schmidt and colleagues argued it would ultimately cost less than other adjunct cleaning options. Encapsulating a bed with antimicrobial copper would cost approximately $2,200 per bed, amortized over 5 years for a total of $1.20 per bed per day. The authors said that additional daily cleaning ($12-$13/room), ultraviolet radiation ($10/room), or hydrogen peroxide vapor phase deposition ($100/room) would be much more expensive.

“The copper intervention … is the only adjunct to act continuously, actively killing bacteria … and only adding a modest increase to the environmental services/infection control budget,” they wrote. “The value delivered by this intervention to the infection control bundle warrants further studies to assess its impact on HAI rates ultimately leading to consideration for its adoption.”