During a hernia operation, Dorothea Handron’s surgeon unknowingly pierced her bowel. It took five days for doctors to determine she had an infection. By the time they operated on her again, she was so weakened that she was placed in a medically induced coma at Vidant Medical Center in Greenville, North Carolina.
Comatose and on a respirator for six weeks, she contracted pneumonia. “When they stopped the sedation and I woke up, I had no idea what had happened to me,” said Handron, 60. “I kind of felt like Rip Van Winkle.”
Because of complications like Handron’s, Vidant, an academic medical center in eastern North Carolina, is likely to have its Medicare payments docked this fall through the government’s toughest effort yet to crack down on infections and other patient injuries, federal records show.
A quarter of the nation’s hospitals – those with the worst rates – will lose 1 percent of every Medicare payment for a year starting in October. In April, federal officials released a preliminary analysis of which hospitals would be assessed, identifying 761. When Medicare sets final penalties later this year, that list may change because the government will be looking at performance over a longer period than it used to calculate the draft penalties. Vidant, for instance, says it lowered patient injury rates over the course of 2013, and Handron praises their efforts.
The sanctions, estimated to total $330 million over a year, kick in at a time when most infections measured in hospitals are on the decline, but still too common. In 2012, one out of every eight patients nationally suffered a potentially avoidable complication during a hospital stay, the government estimates. Even infections that are waning are not decreasing fast enough to meet targets set by the government. Meanwhile new strains of antibiotic-resistant bacteria are making infections much harder to cure.
Dr. Clifford McDonald, a senior adviser at the federal Centers for Disease Control and Prevention, said the worst performers “still have a lot of room to move in a positive direction.”
Are The Metrics Right?
Medicare’s penalties are going to hit some types of hospitals harder than others, according to an analysis of the preliminary penalties conducted for Kaiser Health News by Dr. Ashish Jha, a professor at the Harvard School of Public Health. Publicly owned hospitals and those that treat large portions of low-income patients are more likely to be assessed penalties. So are large hospitals, hospitals in cities and those in the West and Northeast. Preliminary penalties were assigned to more than a third of hospitals in Alaska, Colorado, Connecticut, the District of Columbia, Nevada, Oregon, Utah, Wisconsin and Wyoming, Medicare records show.
“We want hospitals focused on patient safety and we want them laser-focused on eliminating patient harm,” said Dr. Patrick Conway, chief medical officer of the Centers for Medicare & Medicaid Services.
The biggest impact may be on the nation’s major teaching hospitals: 54 percent were marked for preliminary penalties, Jha found. The reasons for such high rates of complications in these elite hospitals are being intensely debated. Leah Binder, CEO of The Leapfrog Group, a patient safety organization, said academic medical centers have such a diverse mix of specialists and competing priorities of research and training residents that safety is not always at the forefront. Nearly half of the teaching hospitals — 123 out of 266 in Jha’s analysis —had low enough rates to avoid penalties.
The government takes into account the size of hospital, the location where the patient was treated and whether it is affiliated with a medical school when calculating infection rates. But the Association of American Medical Colleges and some experts question whether those measures are precise enough. “Do we really believe that large academic medical centers are providing such drastically worse care, or is it that we just haven’t gotten our metrics right?” Jha said. “I suspect it’s the latter.”
Medicare assigned a preliminary penalty to Northwestern Memorial Hospital in Chicago, for instance, but Dr. Gary Noskin, the chief medical officer, said hospitals that are more vigilant in catching problems end up looking worse. “If you don’t look for the clot, you’re never going to find it,” he said.
Another concern is there may be little difference in the performance between hospitals that narrowly draw penalties and those that barely escape them. That is because the health law requires Medicare to punish the worst-performing quarter of the nation’s hospitals each year, even if they have been improving.
“Hospitals that have been working hard to reduce infections may end up in the penalty box,” said Nancy Foster, vice president for quality and public safety at the American Hospital Association.
Third Leg Of Medicare’s Pay-For-Performance
The Hospital-Acquired Condition (HAC) Reduction Program, created by the 2010 health law, is the third of the federal health law’s major mandatory pay-for-performance programs for hospitals. The first levies penalties against hospitals with high readmission rates and the second awards bonuses or penalties based on two dozen quality measures. Both are in their second year. When all three programs are in place this fall, hospitals will be at risk of losing up to 5.4 percent of their Medicare payments.
In the first year of the HAC penalties, Medicare will look at three measures. One is the frequency of bloodstream infections in patients with catheters inserted into a major vein to deliver antibiotics, nutrients, chemotherapy or other treatments. The second is the rates of infections from catheters inserted into the bladder to drain urine. Both those assessments will be based on infections during 2012 and 2013.
Finally, Medicare will examine a variety of avoidable safety problems in patients that occurred from July 2011 through June 2013, including bedsores, hip fractures, blood clots and accidental lung punctures. Over the next few years, Medicare will also factor in surgical site infections and infection rates from two germs that are resistant to antibiotic treatments: Clostridium difficile, known as C. diff, and Methicillin-resistant Staphylococcus aureus, known as MRSA.
Vidant is worse than average in catheter-associated urinary tract infections and serious complications from surgery in the latest statistics Medicare published on its Hospital Compare website. But in more recent data the medical center voluntarily reports on its website, the number of catheter and urinary tract infections dropped during 2013. Joan Wynn, Vidant Health’s chief quality and safety officer, said complications rates are dropping this year as well.
The prospect of penalties is “difficult when you know how much your performance is improved,” said Wynn. She said Vidant has taken many steps to reduce complications, added patients to internal committees and now reveals on its website the number of infections, patient falls, medication errors and bed sores.
Vidant asked Handron, a retired nursing professor injured in 2009, to tell her experience to the trustees and make a video for the medical staff talking about it. She continues to advise the hospital. “I know they’re going in the very right direction,” Handron said. “I would have absolutely zero concern about myself or a family member going to Vidant for anything now.”
Nationally, rates of some infections are decreasing. Catheter-related infections, for instance, dropped 44 percent between 2008 and 2012. Still, the CDC estimates that in 2011, about 648,000 patients—1 in 25—picked up an infection while in the hospital, and 75,000 died.
Rates of urinary tract infections have not dropped despite efforts. These infections are more likely the longer a line is left in, but sometimes they are not removed promptly out of convenience for the nurse or patient or simply institutional lethargy. Swedish Medical Center in Seattle, which has higher urinary catheter infection rates than do most hospitals, has given nurses more authority to remove catheters so long as they follow guidelines for when removal is appropriate, said Dr. Michael Myint, Swedish’s vice president for quality and patient safety. “Historically, they would just wait for the physician’s order to come through,” Myint said.
Medicare has been pressuring hospitals for several years to lower rates of injuries to patients. In 2008 Medicare started refusing to reimburse hospitals for the extra cost of treating patients for avoidable complications. A subsequent study by Harvard researchers found no evidence that the change led to lower infection rates.
“With infections, we are moving in the right direction,” said Lisa McGiffert, who directs the patient safety program at Consumers Union, “but I would not say we are anywhere near where we need to be.”
Patient Advocates Praise Move
Patient advocates say the financial penalties are long overdue, given how little accountability there has been. Gerald Guske discovered that in 2012 when he went into Martha Jefferson Hospital in Charlottesville, Virginia, for an artificial hip implant. Doctors later had to reopen the incision and wash out Guske’s implant. Guske, a retired electronic technician, was laid up for a month in a rehabilitation facility while strong antibiotics were pumped directly into a vein.
Martha Jefferson told Guske it had followed proper protocols. “Unfortunately, infection is a known risk of any surgery, and even when everything is performed correctly and conditions are ideal, they can occur,” the hospital wrote him afterward. “Infection does not necessarily indicate that something went wrong.”
Martha Jefferson Hospital said it could not discuss the case because of patient privacy laws. The hospital’s infection control specialist, Dr. Keri Hall, said infection rates have been dropping and “we are every day doing what we can to hopefully bring our rates down to zero.”
Guske said he has fully recovered, “other than taking six weeks out of my life,” but he attributes the stress around his complications to a minor stroke his wife suffered. He said state regulators told him they could not take any action because the hospital followed proper procedures. The fear of a financial penalty against a hospital, Guske said, is “the only thing that’s really going to change matters.”
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