This policy is a first significant step to move output-based inpatient funding to outcome-based funding. The policy is one of the most large-scale and visible pay-for-performance initiatives ever attempted in the US healthcare system. It is also the most important effort yet made to address the growing problem of HAIs. The list of preventable infections affected by the CMS hospital-acquired condition policy is likely to grow in the future. CMS is already considering adding ventilator-associated pneumonia, bloodstream infections due to Staphylococcus aureus, Clostridium difficile-associated disease, and methicillin-resistant Staphylococcus aureus to the new reimbursement policy. Understanding the ramifications of this policy, both for HAIs and for safety improvement in general, is critical to future quality improvement.
CMS has estimated that the total nationwide payment impact of the new policy amounts $20 million in the first year and $50 million in subsequent years, signifying an average impact of approximately $12,500 per hospital. An independent study, however, has indicated that the payment impact may be as low as $2.4 million nationwide (~$600 per hospital). Anecdotally, the policy appears to have engaged hospital communities and received extensive and protracted media coverage asserting significant financial impact for individual hospitals prior to implementation. To date, the preimplementation impact of the policy has not been evaluated and therefore it may never be possible to estimate its full impact.
As with many new policies, although a number of potential outcomes can be hypothesized, the actual consequences may be surprisingly different. Under the most positive scenarios the financial incentive provides motivation for hospitals to improve processes, implement evidence-based practice recommendations and reduce the rate of HAIs.14
Under a less optimistic scenario, hospitals will recognize that the reduction in revenue is limited and modify administrative and billing practices sufficiently to “work around” and limit the impact of the CMS policy, without implementing initiatives that will reduce the infection rate.40
An even more pessimistic scenario is that the policy results in perverse incentives for hospitals to provide care below present standards of quality while adopting defensive measures to protect themselves from potential revenue losses by shunning patients who are likely to develop HAIs.
Because of the diversity of these potential outcomes, and their important implications for healthcare quality and costs, all participants in the conference agreed that research to evaluate the consequences of the policy change should begin immediately. A broad array of research topics was identified. Studies beginning soon will have the best hope of capturing data for the years preceding the policy change, a key element in nonexperimental research. Indeed, for many of the research agenda items, specific data (such as clinician behavior and compliance with guidelines) needs to be collected prospectively. Moreover, early results of research are likely to help CMS modify the payment regulations in the coming years. The CMS payment policy offers an excellent opportunity to understand and influence the use of financial incentives for improving patient safety.
While the research agenda developed is specific to HAIs, many of the items are also appropriate to the other hospital-acquired conditions. For example, there are similar definitional issues with pressure ulcers. With healthcare reform likely, there are many other important policy changes on the horizon (eg, bundled payments, disease management, and medical homes). Developing research agendas around these changes would also be worthwhile activities.