Not paying for catheter-associated urinary tract infections: more difficult than it seems?

Policy interventions that attempt to influence patient care can be hard to implement and their desired outcomes can be slow to achieve. The efforts of the Centers for Medicare and Medicaid Services (CMS) to reduce preventable infections by withholding payment for additional expenses related to catheter-associated urinary tract infections (CAUTI) illustrate this challenge clearly. In October of 2008, CMS began a policy of refusing to pay hospitals for additional costs related to CAUTI and 7 other potentially preventable events or conditions. The list was expanded to include 3 new conditions in 2013. CAUTIs represent more than one third of all hospital-acquired infections and are costly to treat. Medicare patients appear to have much higher rates of CAUTIs compared with other groups. Initial reactions to the rule varied widely. Some observers predicted large reductions in hospital revenue and others suggested that hospitals might compensate by charging for more complicated conditions or comorbidities and by relying on outlier payments to cover additional time spent in the hospital to treat the infection. CMS predicted savings from the new rule of $21 million–$22 million per year between 2010 and 2014 from reduction in reimbursement for the 8 original hospital-acquired conditions combined. Follow-up studies using hospital discharge reports from a single state, the National Hospital Discharge Survey, or the National Healthcare Safety Network (NHSN), a reporting system maintained by the Centers for Disease Control, show that CAUTIs have not declined significantly since the policy was implemented. The study by [authors] suggests at least 2 reasons why the nonpayment initiative has not been more effective in reducing CAUTIs. The first problem was a flawed monitoring system. Any new policy must have a way to accurately track the behaviors it seeks to influence. As [authors] and others describe, CMS originally relied on International Classification of Diseases-9th revision (ICD-9) codes on Medicare claims to identify CAUTI; this method was ineffective because the codes required to identify CAUTI events were often not reported on claims. A further complication was introduced when CMS asked providers to report new “present on admission” codes after the 2008 implementation date. Any change that requires providers to record and report new data may take time to implement. Further, because claims are primarily used for paying providers, there was a weak incentive to record an unreimbursable condition. Moreover, earlier studies showed that catheter placement is not always recorded accurately in physician notes in medical records, which are the source of billing codes. To address the issue of underreporting in their analysis, [authors] used the NHSN to identify CAUTIs, then linked infection reports to Medicare claims to compare payments for patients with a CAUTI to a similar group without evidence of a urinary tract infection. Because the NHSN was specifically designed to monitor health care–associated infections, it was less likely to suffer from the type of underreporting observed in claims.