Hospitals may have avoided financial penalties by billing hospital-associated conditions as present at the time of the patient's admission -- supporting prior work showing that a Medicare policy designed to monetarily penalize hospitals for preventable complications had an insignificant impact on reducing healthcare-associated infections, new research shows.
In addition, the targeted billing codes were rarely used by hospitals, far less than expected based on national estimates. And even when hospitals billed for HACs during a hospitalization, this infrequently affected the diagnosis-related group assignment, impacting hospital reimbursement.
The Centers for Medicare and Medicaid Services had hoped the policy would focus more attention on improving care quality, but instead it appears most of the changes have been to coding practices, the research showed.
In 2008 CMS' Hospital Inpatient Prospective Payment System ceased reimbursement for HACs not present on admission -- putting the cost of infections acquired in a health system on the provider -- with the intent to encourage hospitals to adopt or strengthen infection prevention measures. Prior research discovered that this change in policy did not have an impact on rates of HACs. Rather, providers were coding these HACs as present on admission.
To understand why this trend was happening, researchers analyzed over 65 million Medicare fee-for-service hospitalizations from 2007 to 2011 in acute care facilities. They specifically looked at documentation for central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), and whether the codes for those HACs were submitted with a present on admission, or POA designation, which are not counted against a hospital as a preventable complication.
They found that CLABSI and CAUTI affected 0.23 percent and 0.06 percent of hospitalizations, respectively, and in the three years immediately after the 2008 CMS policy implementation, 82 percent of the CLABSI codes and 91 percent of CAUTI codes were marked as present on admission, or POA -- which researchers noted was a significant increase in the use of the present-on-admission designation compared to before the CMS HAC Policy.
Diagnosis coding for CAUTI and CLABSI that was not present on admission from 2007 to 2011 showed a dramatic decrease. For example, in 2007 hospitals discharged 6,172 patients with a CAUTI diagnosis code, 99.8 percent of which had a POA=No designation. This compares to 2011 when 6,448 patients were coded as having a CAUTI, representing only 10.7 percent of those who had the POA=No designation.
For discharges that were subject to penalty, there was a financial impact on only 0.4 percent of the hospitalizations with a CLABSI code and 5.7 percent with a CAUTI code. These penalties infrequently impacted hospital reimbursement and the researchers suggest that this is partly to blame for the lack of impact from the policy.