Making the CMS payment policy for healthcare-associated infections work: organizational factors that matter.

Healthcare-associated infections (HAIs) are among the most common adverse events in hospitals, and the morbidity and mortality associated with them are significant. In 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a new financial policy that no longer provides payment to hospitals for services related to certain infections not present on admission and deemed preventable. At present, little is known about how this policy is being implemented in hospital settings. One key goal of the policy is for it to serve as a quality improvement driver within hospitals, providing the rationale and motivation for hospitals to engage in greater infection-related surveillance and prevention activities. This article examines the role organizational factors, such as leadership and culture, play in the effectiveness of the CMS policy as a quality improvement (QI) driver within hospital settings. Between late 2009 and early 2010, interviews were conducted with 36 infection preventionists working at a national sample of 36 hospitals. We found preliminary evidence that hospital executive behavior, a proactive infection control (IC) culture, and clinical staff engagement played a favorable role in enhancing the recognition, acceptance, and significance of the CMS policy as a QI driver within hospitals. We also found several other contextual factors that may impede the degree to which the above factors facilitate links between the CMS policy and hospital QI activities.

Episode of care analysis reveals sources of variations in costs.

OBJECTIVES: To understand and reveal the underlying sources of inter- and intraplan variation in a selected number of chronic and procedural episodes. STUDY DESIGN: Analysis of allowed claims from 9 regional health plans covering commercially insured populations in different areas of the United States. METHODS: Use of the PROMETHEUS Evidence-Informed Case Rates analytics to 1) calculate total plan costs and cost of specific episodes, 2) create price and severity adjustments, and 3) determine coefficients of variation. RESULTS: The interplan coefficients of variation for total per member per year costs and per episode costs vary from 0.1 to 0.55, while the intraplan coefficients of variation vary from 0.4 to 5.5. In both analyses, the coefficients of variation for potentially avoidable complications (PACs) were higher than the coefficients of variation for typical costs. CONCLUSIONS: There is significant variation in episode costs within a plan, and PACs have significantly more variation than typical costs. Plans and accountable care organizations would benefit from understanding the source of variation of their episode costs in order to improve overall cost of care.

No payment for preventable complications: reviewing the early literature for content, guidance, and impressions.

In 2008, the Centers for Medicare & Medicaid Services (CMS) implemented a policy of not paying hospitals for the care of several preventable hospital-acquired conditions. The CMS policy is a unique value-based purchasing initiative because it relies on penalties rather than on rewards. Because of its novelty, less is known in advance about how this type of payment approach might work, get implemented, or be viewed by stakeholders in health care. As a result, the early published literature focusing on the CMS policy may serve as an important frame of reference among managers, policy makers, and researchers for guiding attitudes and behaviors. This review examines over an initial 3-year period academic and trade articles addressing the CMS policy to gain the impressions, guidance, and content provided in this literature. Key findings include an inordinately small number of articles focused on the new CMS policy; little original research or empirical prediction on CMS policy implementation and outcomes; a highly opinionated, non-evidence-based literature; a literature less able to address the policy impact for specific preventable complications or hospital settings; and a high percentage of articles making inconsistent, broad-based linkages between the CMS policy and specific quality improvement initiatives that potentially limit the policy's long-term acceptance as an improvement strategy.