FEEDBACK WK3

Please see the attached task and write a 600-800 response with support references. Please do not re-write what the writer says or use their references, use your own original thoughts. You don’t have to respond to the entire post, just pick out a few highlights and comment on them with supportive references. The attached document can be used as a help aid for the kind of response that will satisfy this task.  Thanks in advance.

What is the problem that is being addressed? 

What can the government do to address healthcare associated conditions that were derived from a healthcare institution that compromises patient safety and quality of care?

 Hospital Acquired Conditions (HACs) are conditions that are contracted by patients in the hospital setting during their acute hospitalization that they did not have prior to being admitted to the hospital.

 Improving patient safety in hospitals is an important goal for the U.S. Department of Health and Human Resources (HHS) and CMS. According to the Centers for Disease Control and Prevention (CDC), approximately one out of every 25 hospital patients has at least one healthcare associated infection (CDC.gov, 2016).  In 2014, results of a project known as the Heathcare Associated Infection (HAI) Prevalence Survey described the burden of HAIs in U.S. hospitals and reported that in 2011, there were an estimated 722,000 HAIs in U.S. acute care hospitals and about 75,000 patients with HAIs died during their hospitalizations (CDC.gov, 2016). These complications add as much as $4.5 billion to hospital costs paid each year by taxpayers, and insurers and consumers (CDC.gov, 2016).

In an effort to save taxpayer dollars, the Tax Relief and Health Care Act of 2006 required that the Office of Inspector General (OIG) report to Congress regarding the incidence of “never events” among Medicare beneficiaries (Miller, 2015).  The OIG determined that Medicare spent approximately $4.4 billion per year on preventable adverse events in hospitals (Miller, 2015). In 2010 adult patients experienced roughly 4.8 million HACs out of 32.8 million hospital discharges, based on reviewing medical records from the Medicare Patient Safety Monitoring system and data from the Agency for Healthcare Research and Quality and the NationalHealthcare Safety Network. HACs result in longer hospital stays which can lead to poor patient outcomes and higher spending onhealthcare.

 Previously Medicare payment was based on the volume of services provided; the sicker the patient the more likely they would need more services and therefore Medicare would pay hospitals and other providers more for treating those patients, even if the need for the additional services was caused by a condition acquired from the care provided in the hospital setting.

 The Inpatient Prospective Payment System (IPPS) assigns a patient’s ailment to a payment group called the diagnosis-related group (DRG) based on the acute diagnosis the patient comes into the hospital with along with addressing and continuing to treat their chronic medical conditions that were being catered to outside of the hospital. In October of 2008, CMS no longer assigned a patient to a higher paying DRG for conditions that were not present on admission to the hospital, thereby discontinuing additional payments for certain hospital acquired conditions that were deemed preventable (Lee, 2012).

 Describe the Solution. 

The Affordable Care Act expanded the previous program “never events” that penalized hospitals for avoidable threats to the safety of Medicare patients. Section 3008 of the Patient Protection and Affordable Care Act established, on October 1st 2014, the HealthcareAcquired Condition (HAC) Reduction Program (CDC.gov, 2016). The program requires the Secretary of the Department of Health and Human Services to adjust payments to applicable hospitals that rank in the worst –performing quartile of all subsection (d) non-Maryland hospitals with respect to risk-adjusted HAC quality measures (CDC.gov, 2016). These hospitals will have their payments reduced to 99 percent of what would otherwise have been paid for by their DRG discharge. There are two domains; Domain 1 measures are derived from the Agency for Healthcare Research and Quality (AHRQ) and Patient Safety Indicator (PSI) 90 Composite and Domain 2 measures are derived from the CDC, National Healthcare Safety Network (NHSN) to reduce acquired infections (CDC.gov, 2016).

 Domain 1.

AHRQ and PSI 90 Composite includes the following eight PSIs; 1. Pressure ulcer, 2. Iatrogenic pneumothorax, 3. Central Venous Catheter-related Bloodstream infections, 4. Postoperative Hip Fracture, 5. Perioperative Pulmonary Embolism or Deep Vein Thrombosis, 6. Postoperative Sepsis, 7. Postoperative Wound Dehiscence and 8. Accidental Puncture or Laceration (CDC.gov, 2016).

 Domain 2.

The U.S. Department of Health and Human Services (HHS) hospital mission is to improve the quality of care and patient safety at our hospitals, by continually striving to achieve better health outcomes at a lower cost. HHS developed a National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination (Health.gov, 2016). HHS convened the Federal Steering Committee for the Prevention of Health Care-Associated Infections. The Steering Committee’s charge is to coordinate and maximize the efficiency of prevention efforts across the federal government. There are 3 phases to the Action Plan and in this report I will focus on phase one, Acute Care Hospitals. Healthcare Associated infections (HAIs) identified 8 action plan measures that needed addressed. They have new targets for December 2020 extrapolated from January 2015 baseline Data; 1. 50% reduction form 2015 baseline in central line associated bloodstream infections (CLABSI) in intensive care units and ward located patients; 2. 25% reduction from 2015 baseline in catheter- associated Urinary tract infections (CAUTI); 3. 75% reduction from 2015 baseline in incidence of Invasive health care-associated methicillin-resistant Staphlococcus aureus (MRSA) infections; 4. 50% reduction from 2015 baseline in reducing facility-onset methicillin-resistant Staphlococcus aureus (MRSA) in facility wide healthcare; 5. 30% reduction from 2015 baseline on reducing facility-onset Clostridium difficile infections in facility-wide healthcare; 6. 30% reduction from 2015 baseline of the rate of Clostridium difficile hospitalizations; 7. 30% reduction from 2015 baseline to reduce Surgical Site Infections (SSI) from admission and readmissions; 8. Suspended from HAI action plan of Surgical Care improvement Project (SCIP) which measures adherence to process measures to prevent Surgical Site Infections (Health.gov, 2016).

The 2016 Fiscal year results showed that 758 out of 3308 hospitals subject to the HAC Reduction Program are in the worst performing quartile and will have a 1 percent payment reduction applied to all Medicare discharges occurring between October 1, 2015 and September, 2016. (CDC.gov, 2016). In Fiscal year 2015, 724 hospitals were subjected to a payment reduction; estimated total savings will be around $364 million (CDC.gov, 2016).

 The ACA requires CMS to publically report hospitals performance information. Under Inpatient Quality Reporting (IQR) program, hospitals that do not submit data on specific quality measures receive a payment update that is 2 percentage points lower than that paid to hospitals that submit data which correlate and align with many categories of the conditions subject to the HAC payment provision (CDC.gov, 2016). Under Medicare’s Hospital value-based purchasing program, a hospital’s actual performance on certain measures affects whether the hospital’s base payments under the inpatient prospective payment system (IPPS) are adjusted up or down. Although 15,000 lives have been saved due to the prevention of HACs in recent years, there is still substantial room for improvement (Innovation.cms.gov, 2016)

 With the Law in place and patient experience/satisfaction embedded in reimbursement. It behooves hospitals/Accountable Care Organizations to adapt and comply with patient safety and quality of care initiatives.

 3. Discuss the Stakeholders (support and opposition)

 There are many stakeholders in regards to the HAC reduction program. Some of these include American Hospital Association, Association of American Medical Colleges, Federation of American Hospitals, Medicare Payment Advisory Commission (MedPAC), Administration for Community Living (ACL), AHRQ, CDC, CMS, FDA, Health Resources and Service Administration, Indian Health Services, National Institute of Health, Office of Secretary, Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Planning and Evaluation, Office of the Assistant Secretary for Public Affairs, Office of the National Coordinator for Health Information Technology, U.S. Department of Defense, U.S. Department of Labor and U.S. Department of Veteran Affairs.

 The American Journal of Infection control suggested that while experts recommend hospitals use urinary catheters as rarely as possible to limit the chance of infections, those same hospitals may look worse because catheters that used are mostly used in the sickest patients, who are more prone to infection (miramedge.com, 2016).

 A Study published in the Journal of the American Medical Association examined the first year of the program and found that the hospitals that were penalized were more likely to have characteristics usually associated with quality. These include accreditation by the Joint Commission, the presence in most trauma centers and those centers that have more nurses per patient. Analysis of the data from the proposed rule for fiscal year 2015 found that a large, urban, public, major teaching hospital with a high percentage of poor patients had a 62% chance of receiving a HAC penalty while small, rural, for profit, no teaching hospital in the South with few poor patients had a nine percent chance of getting the penalty (miramedge.com, 2016)

The penalties are punitive and are levied inappropriately against places that have made progress in safety but have not caught up to most facilities. No matter how much progress is made in reducing the number of HACs, or whether the performance of the poorest performing hospitals is substantially different from that of hospitals in the other quartiles, the law requires Medicare to penalize one quarter of hospitals each year.

 Stakeholders against the composition of the HAC reduction program identify numerous problems within the Domain criteria one of which is the inclusion of PSI- 90 (rwjf.org, 2016). They do not feel that the components reflect the relative importance of the hospital’s ability to prevent its occurrence. They also argue that claims-based measures do not fully reflect the patient’s clinical history and care and present an inexact picture of the quality of care provided (rwjf.org, 2016).

 Performance on the measure is affected by whether or not the hospital has identified and reported complicating conditions on its claims, thus creating a surveillance bias, whereby hospitals that are more vigilant about identifying complications are more likely to perform poorly on the measure (rwjf.org, 2015). Another component measure focuses on surgical issues, hospitals with large volumes of surgeries such as academic medical centers and large urban hospitals are more likely than other types of hospitals to be subject to penalties.

 Stakeholders who favor the HAC Reduction Proram argue that the measures in each domain also can be applied to reduce other types of preventable harm. For example, it is also associated with a 70% reduction in ventilator-associated pneumonia, a lung infection, a breathing tube in the patients airway that is connected to a ventilator (Pronovost, 2011).

 The Joint Commission, which licenses and accredits health care organizations, established a national patient safety goal to reduce bloodstream infections and also support the HAC reduction program.

 Hospital associations have concerns with how Congress designed the program and how CMS is implementing it. The statue requires the lowest-performing hospitals to be subjected to the penalty regardless of whether the hospital’s performance is improving or whether the performance of the poorest-performing hospitals is substantially different from that of hospitals in other quartiles (rwjf.org, 2015). The language associated with the Social Security Act applies penalties to “the amount of payment that would otherwise apply” and does not exclude payment adjustments such as disproportionate –share hospital or teaching hospital status from application of the penalty, resulting in a significantly greater impact on quality adjustments associated with those in the VBP program and the Readmission Hospital Reduction Program for which the adjustment applies only to the base operating payment before those adjustments are made. (rwwjf.org, 2015).

 CMS acknowledges these concerns and issues with claims based measures in general but argue that claims data represent a widely available data source that produces minimal administrative and financial burden on hospitals (CMS.GOV, 2016). However, CMS is also adjusting its targets on reduction as hospitals are adapting to the domains with both reduction percent and the weight of the NHSN measured (CMS.gov, 2016).

With the adjustment from Fee for Service to Value Based Purchasing, organizations as well as consumers are keen to acknowledge the importance of quality of care and the patient experience during their hospitalization.

Why do you think this element was included in the final legislation.

 The incremental approach to leveraging patient safety and quality of care associated with HAC reduction program as evidenced by the initial data has helped policy development. Studies have shown that the average performance across all hospitals in the database improved for two of three measures in the program’s second year (miramedge.com, 2016). The previous Deputy CMS Administrator, Patrick Conway MD, stated that CMS continues to examine data adjustment for ways to improve patient safety. Trying to integrate the many policies in the Patient Protection and Affordable Care Act in its infancy is demanding. With healthcareorganizations being more transparent with public reporting about their performance, further updates to the HAC reduction program can continue to improve patient safety and quality of care. With all the data that is being collected, it may be difficult to distinguish what is important and what is not. Dr. Ashish Jha, MD of the Harvard T.H. Chan School of Public health commented that real improvement will only come when the penalties are based on a much broader representation of the types of medical problems patients can experience for example, the most common cause of problems in hospitals is medication errors, which remains absent from the program (Jha, 2016). I do agree with the notion of reducing HAC and learning from the solutions that is impacting patient safety and quality. We will soon be better analyzing these through real-time means such as the Electronic Medical Records and cloud based technology. There are certain measures that Hospitals and its healthcare providers can control and this should be acknowledged by the government. Expanding the measures in the HAC Reduction Program to consider socioeconomic and demographic factors would help provide a better understanding of the meaningful use of these factors to reduce bias when comparing hospitals. As a provider of healthcare in the hospital setting it is important to work with government officials and policymakers as they ultimately have control over this situation as they hold the power to expand this reform and improve compliance.

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