Infection Control & Hospital Epidemiology (2018), 39, 897–901 doi:10.1017/ice.2018.137


Original Article


Centers for medicare and medicaid services hospital-acquired conditions policy for central line-associated bloodstream infection (CLABSI) and cather-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement


Michael S. Calderwood MD, MPH1, Alison Tse Kawai ScD2, Robert Jin MS2 and Grace M. Lee MD, MPH2,3 1Section of Infectious Disease and International Health, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, 2Department of Population Medicine,


Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts and 3Department of Pediatrics, Stanford University School of Medicine, Stanford, California


Abstract


Objective: In 2008, the Centers for Medicare and Medicaid Services (CMS) stopped reimbursing for hospital-acquired conditions (HACs) not present on admission (POA). We sought to understand why this policy did not impact central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) trends. Design: Retrospective cohort study. Setting: Acute-care hospitals in the United States. Participants: Fee-for-service Medicare patients discharged January 1, 2007, through December 31, 2011. Methods: Using inpatient Medicare claims data, we analyzed billing practices before and after the HAC policy was implemented, including the use and POA designation of codes for CLABSI or CAUTI. For the 3-year period following policy implementation, we determined the impact on diagnosis-related groups (DRG) determining reimbursement as well as hospital characteristics associated with the reimbursement impact. Results: During the study period, 65,205,607 Medicare fee-for-service hospitalizations occurred at 3,291 acute-care, nonfederal US hospitals. Based on coding, CLABSI and CAUTI affected 0.23% and 0.06% of these hospitalizations, respectively. In addition, following the HAC policy, 82% of the CLABSI codes and 91% of the CAUTI codes were marked POA, which represented a large increase in the use of this designation. Finally, for the small numbers of CLABSI and CAUTI coded as not POA, financial impacts were detected on only 0.4% of the hospitalizations with a CLABSI code and 5.7% with a CAUTI code. Conclusions: Part of the reason the HAC policy did not have its intended impact is that billing codes for CLABSI and CAUTI were rarely used, were commonly listed as POA in the postpolicy period, and infrequently impacted hospital reimbursement.


(Received 27 February 2018; accepted 12 May 2018; electronically published June 28, 2018)


To encourage hospitals to invest in quality improvement, the Centers for Medicare and Medicaid Services (CMS) made changes to the Hospital Inpatient Prospective Payment System (IPPS) in 2008. Under these changes, CMS stopped allowing diagnosis codes for hospital-acquired conditions (HACs), such as central line–associated bloodstream infections (CLABSIs) and catheter- associated urinary tract infections (CAUTIs), to qualify for Medicare reimbursement.1 Under IPPS rules, reimbursement for an inpatient hospitalization is determined by the relative weight of billing codes used to assign diagnosis-related groups (DRGs).2


Author for correspondence: Michael S. Calderwood, MD, MPH, Section of Infectious


Disease and International Health, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Suite 5C, Lebanon, NH 03756. E-mail: Michael.S.Calderwood@hitchcock.org Cite this article: Calderwood MS, et al. (2018). Centers for medicare and medicaid


services hospital-acquired conditions policy for central line-associated bloodstream infection (CLABSI) and cather-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement. Infection Control & Hospital Epidemiology 2018, 39, 897–901. doi: 10.1017/ice.2018.137


© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.


By ceasing additional reimbursement for codes associated with CLABSI and CAUTI, it was hypothesized that hospitals would be driven to quickly reduce their HACs.3 Prior work, however, found that the CMS HAC policy did


not impact already declining national rates of CLABSIs and CAUTIs.4 While the CMS HAC policy did get the attention of hospital leadership and focused attention on healthcare-associated infections,5,6 surveys found that more effort was focused on the documentation of conditions present on admission (POA) rather than on implementing practice changes.5 Concern was also raised that differences across hospitals were more a reflection of differ- ences in coding practices rather than differences in quality.7 To further understand why the CMS HAC policy may not


have had its intended outcome, we studied the impact of this policy on the DRG assignment for Medicare hospitalizations with coded CLABSI and CAUTI events. Furthermore, we examined changes in coding practices following the implementation of the CMS HAC policy.

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