Medicare targets Pittsburgh-area hospitals

Facilities’ infection, injury rates examined

Several Pittsburgh-area hospitals are among the more than 750 nationwide at risk of being financially punished by Medicare for having greater-than-usual hospital-acquired infection and injury rates.

UPMC Presbyterian-Shadyside, Magee-Womens Hospital of UPMC, UPMC Passavant, Allegheny Health Network’s Forbes Regional Hospital, Johnstown’s Conemaugh Memorial Medical Center, Beaver’s Heritage Valley Medical Center, Butler Memorial Hospital, Clarion Hospital and Grove City Hospital are on the preliminary penalty list, meaning they scored in the bottom quartile of hospitals.

In Erie, Allegheny Health Network’s Saint Vincent Hospital was ranked as one of the worst offenders. It is, for now, at the risk of losing 1 percent of its Medicare funding, a penalty that will extend Oct. 1 through Sept. 30, 2015. On a scale of 1 to 10, with larger numbers indicating the greater level of risk for “hospital acquired-conditions,” Saint Vincent scored a 10.

Allegheny Health Network is the 1-year-old hospital system that Pittsburgh’s Highmark Health owns.

Hospitals appearing on the preliminary penalty list, which was issued this spring, have a chance to improve their infection rates before the final penalty list is issued later this year. In its first years, the Hospital-Acquired Condition (HAC) Reduction Program measures bloodstream infections at catheter sites and urinary tract catheter infections, as well as avoidable injuries and infections such as bedsores and fractures.

“Saint Vincent has improved its performance significantly since the time period reflected in the report,” AHN spokesman Dan Laurent said. “Our internal projection, due to those improvements, is that we will not incur the HAC penalty for the current CMS year and believe we will be even less at risk for the penalty in the [next] fiscal year.”

The penalty system, which will amount to about $330 million in withheld payments for the upcoming federal fiscal year across the country, is meant to force health care providers to confront hospital-acquired infection rates.

The rates have been falling for years, but the federal Affordable Care Act considers them still too high. The U.S. Centers for Disease Control and Prevention estimates that 1 in 25 inpatients on any given day, about 4 percent, “is battling an infection picked up in a hospital or other health care facility,” according to a new CDC survey.

That’s about 600,000 hospital patients each year, which is well less than the 1.7 million-a-year estimate that prevailed through the 1990s and the 2.1 million annual figure that was the 1970s estimate.

Hospitals are duty-bound to continue the battle against hospital-associated infections and complications, said UPMC’s chief quality officer, Tami Minnier, but a system that punishes a specific percentage of hospitals each year is an arbitrary and unfair one, she said. For example, hospitals that end up in the bottom quartile of performers in consecutive years but make improvements every year aren’t rewarded for that improvement.

Since Medicare tabulates the infection data using the hospitals’ own billing data, those that are most diligent about self-reporting are likely to have higher rates, hospitals say.

“Whenever we start to use billing data [to] describe patient outcomes, it’s not the right approach,” Ms. Minnier said.

Ms. Minnier also said big teaching hospitals and hospitals in urban or high-poverty areas have built-in challenges that can cause higher infection rates. It’s an argument that’s also being made in Washington, D.C. — a bill now under consideration in the Senate would change Medicare’s Hospital Readmissions Reduction Program so hospitals treating large low-income populations aren’t unfairly penalized.

Medicare is trying to adjust for those environmental factors by noting the size and location of a hospital and its medical school affiliation before assessing a final infection and injury grade. Still, the line separating the “passing” hospitals from the “failing” hospitals is not only arbitrary, but it’s also razor-thin.

“None of these are big event numbers,” Ms. Minnier said. “We’re not talking in the hundreds; we’re talking in the tens. [Fewer] than 10 cases could bump” a hospital from the passing column to the penalty list and could result in that hospital losing 1 percent of its Medicare funding for the year.

Given that Medicare often accounts for 40 percent or more of a hospital’s total patient revenue, 1 percent could equal hundreds of thousands, or even millions of dollars a year, in lost money for a hospital with hundreds of beds.

Still, with this public policy experiment, Medicare “is trying to introduce quality into the mixture,” said Trish Perl, senior epidemiologist at Johns Hopkins Health System. It’s reasonable for Medicare and the public “to expect some kind of accountability” from its hospitals.

Dr. Perl, like others, said Medicare must calibrate its incentives and punishments in order to make sure hospitals don’t “end up robbing Peter to pay Paul.” Cutting hundreds of thousands out of a hospital’s budget could mean the possibility of losing several nurses, which could have the unintended effect of diminishing the quality of care rather than improving it.

By and large, hospitals have been dramatically improving in-house infection rates for decades.

“Things are much better. We’re even impressed with how far we’ve been able to come, but that doesn’t mean that there aren’t places to go.”

HAC is the third prong in Medicare’s new pay-for-performance incentive system, which is meant to reward quality of care rather than quantity of care. The first prong punishes hospitals with high readmission rates, and the second rewards hospitals for hitting certain quality benchmarks.

Bill Toland: or 412-263-2625.

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