PHOENIX The proposed cessation of Medicare reimbursement for management of surgical site infections would have a deleterious impact on hospital finances and create institutional disincentives for surgery on the sicker, more complex patients at increased risk, Joshua A. Cohn said at a congress sponsored by the Association for Academic Surgery and the Society of University Surgeons.
"This [proposed rule] would likely reduce surgical site infection rates due to significant institutional pressure to improve systems of care, but it would also have unintended consequences. It could affect access to care for sick, high-risk patients as well as leading to systems of care directed not at reducing surgical site infections, as the rule intends, but rather at maintaining revenue," observed Mr. Cohn, a medical student at the University of Michigan, Ann Arbor.
Last August, the Centers for Medicare and Medicaid Services proposed rule CMS-1488-P, which as of Oct. 1, 2008, would end reimbursement for the increased care associated with hospital-acquired infections CMS deems preventable. It is clear from the language of the proposal that CMS considers all surgical site infections (SSIs) as falling within this "preventable" category, he added.
It's well established that SSIs tend to occur in preoperatively sicker patients with multiple comorbidities. Leaving aside the issue of whether in fact most SSIs really are preventable, Mr. Cohn and coworkers sought to find out how much of the cost of the added care associated with SSIs is due to the infection independent of the comorbidities.
For this purpose, they turned to the extensive clinical and financial data gathered as part of the National Surgical Quality Improvement Program on a randomly selected population of 5,409 patients who underwent surgery during 20032006 within the University of Michigan Health System.
The 320 patients who developed SSIs had significantly higher preoperative rates of sepsis, chronic obstructive pulmonary disease, and numerous other comorbid conditions, along with increased postoperative complications (see box).
"Patients who were sicker were more likely to get SSIs. And interestingly, most of these factors were obviously beyond the control of the surgical team," Mr. Cohn noted.
In a multivariate linear regression analysis controlling for the significant pre- and postoperative factors related to SSIs, the occurrence of an SSI was independently associated with an $8,304 increased cost to insurers. As a result of this payment, the medical center made a profit of $2,738 per patient with an SSI. Had CMS-1488-P been in effect at the time of the study, however, the hospital instead would have lost an average of $5,566 per patient.
The university's infectious disease specialists place the institutional SSI rate at about 3%. Because 61,000 operations per year are performed within the University of Michigan Health System, that adds up to 1,830 SSIs. If other insurers were to follow the CMS lead, the result would be a $15,200,000 per year loss in revenue.
He predicted that among the consequences of rule 1488-P might be an incentive for hospitals to open new laparoscopic surgery centers, because fewer SSIs occur with laparoscopic procedures.
Audience members expressed dismay that payers would classify SSIs as preventable. They also predicted that, if implemented, 1488-P would fail because it attempts to change physician behavior without affecting physicians' fees.
It is clear that CMS considers all surgical site infections as falling within a 'preventable' category. MR. COHN
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