For the third year in a row, Medicare is penalizing Banner-University Medical Center Tucson for its rate of patient injuries and infections.
The hospital was among the worst-performing 25 percent of hospitals nationwide on a matrix of hospital-acquired conditions, recently released data from the Centers for Medicare & Medicaid Services (CMS) show.
One of two local academic medical centers owned by Phoenix-based Banner Health, Banner-University Medical Center Tucson was the only Tucson hospital penalized by Medicare for the current fiscal year, which began Oct. 1.
An analysis of federal data by Kaiser Health News shows a total of 15 hospitals in Arizona were hit with the penalty, which amounts to a 1 percent reduction in federal Medicare payments through Sept. 30. For some hospitals, the penalty means a cut in payments of a half million dollars or more this fiscal year. Sixteen Arizona hospitals were fined during the last federal fiscal year.
Nationally, 769 of 3,203 hospitals rated will have their payments cut this year, CMS officials say. The federal agency released the data Dec. 19. Children’s, psychiatric, veterans and long-term care hospitals weren’t scored; also excluded were hospitals deemed “critical access” — rural facilities that are often the only hospitals in their area.
While supporters say the penalty program is an effective way to improve patient safety, critics argue it unfairly penalizes hospitals like Banner-University Medical Center Tucson — Southern Arizona’s only top-level trauma center — that deal with the sickest patients with the most complex cases.
Improvements
at Banner
Banner Health did not own Banner-University Medical Center Tucson for much of the data collection period, nor when the hospital was penalized in the first two years of the program, said Dr. Gordon Carr, who is the hospital’s chief medical officer. Banner became owner of the hospital after a merger with the University of Arizona Health Network in March 2015.
The data cited by CMS are drawn from July 2013 through December 2015, Carr emphasized, and do not reflect new investments the company has made and new strategies it has put in place here, he said.
Banner has made “substantial investments” in the clinical infrastructure since the merger, he said. Among other things, the hospital has new central-line protocols, and a new electronic intensive care unit monitoring system that engages a virtual Banner medical team to back up bedside caregivers by constantly monitoring patient vitals for changes that require immediate medical intervention.
Carr said he’s hopeful that more recent improvements will positively affect future CMS reports for the local hospital. He cited Banner-University Medical Center Tucson’s latest data for January through September of this year, which, using the same clinical reporting areas, show a 46 percent reduction in central-line-associated bloodstream infections.
A central line is a catheter inserted into a large vein for diagnostic or therapeutic purposes, such as administering medications. Central-line-associated bloodstream infections (CLABSIs) cause thousands of deaths each year and billions of dollars in added costs to the U.S. health-care system, the Centers for Disease Control and Prevention says.
“Banner Health is committed to continuous quality improvement for the safest, most reliable clinical care,” Carr said.
Reducing infections
The federal penalties were created under the Patient Protection and Affordable Care Act of 2010, also known as Obamacare or the Affordable Care Act (ACA). The penalty program’s official name is the Hospital-Acquired Condition Reduction Program, and it was created to provide incentives for hospitals to improve patient safety and reduce medical costs.
The hospitals are scored on their self-reporting of quality measures, among them central-line-associated bloodstream infections, catheter-associated urinary tract infections (CAUTI), surgical site infection rates for colon and abdominal hysterectomy surgeries, and a composite score of eight patient-safety indicators, among them pressure ulcers, postoperative hip fractures and postoperative sepsis rates.
The government added two more measures to this year’s data: rates of the antibiotic-resistant infections methicillin-resistant staphylococcus aureus (MRSA) and clostridium difficile, often known as C. diff.
Banner-University Medical Center Tucson scored worse than the national benchmark on its rate of central-line-associated bloodstream infections in ICUs and select wards.
The hospital also scored worse than the national benchmark on surgical-site infections from colon surgery, on MRSA infections and on C. diff.
The Centers for Disease Control and Prevention says C. diff, which is shed in feces, was estimated to cause almost half a million infections in the United States in 2011, including 15,000 deaths.
C. diff causes inflammation of the colon and the risk of infection increases with age. The germ can live for long periods on hard surfaces.
Those most at risk are people, especially older adults, who take antibiotics and also get medical care. Any surface, device or material that becomes contaminated with feces may serve as a reservoir for C. diff spores, which CDC officials say are transferred to patients mainly via the hands of health-care personnel who have touched a contaminated surface or item.
Publicly searchable information is on the federal website Hospital Compare, and tells how a hospital compares to the national benchmark.
C. diff is a problem around the country. Other local hospitals that scored worse than the national benchmark on C. diff were Carondelet St. Mary’s Hospital and Tucson Medical Center.
Tucson Medical Center
This year’s data release marked the first time in the three years of the program that Tucson’s largest hospital — Tucson Medical Center — was not penalized.
Tucson Medical Center officials say they have made a concentrated effort in recent years to reduce both hospital-acquired infections and the incidence of the eight patient-safety indicators that are part of the federal scoring system: pressure ulcers; accidental puncture or lacerations; postoperative rupture of a wound incision; postoperative sepsis; blood clots during all phases of surgery; postoperative hip fractures, central venous catheter-related blood stream infections; and lung injuries due to medical care.
Two years ago, TMC scored in the worst 10 percent of hospitals nationwide for its composite patient-safety indicator score. Its score now is in the top 20 percent of all hospitals, chief medical officer Dr. Rick Anderson said.
“We’ve gone from worse than the national average to better than the national average,” he said.
The hospital improved by focusing on three of the eight patient safety indicator areas: pressure ulcers, blood clots, and accidentally puncturing or piercing somebody during surgery, Anderson said.
The hospital looked at best practices in medical literature and “shamelessly stole” protocol from hospitals like Mayo Clinic whose scores are high, Anderson said. “Most hospitals are more than happy to share that because it really is all about protecting patients and keeping them from harm,” Anderson said.
Tucson Medical Center used the Mayo Clinic’s protocol, for example, to reduce its incidence of infection rates following colon surgery.
“We noticed their rate was very low. They actually have something they put in place that starts before the patient even comes to the hospital,” Anderson said. “We put that whole cascade of things in place from before the patient gets here to after the patient leaves. It goes from changing instruments out when you close the colon, to changing gowns, changing instruments, timing of antibiotics, making sure patients’ blood sugars are well-controlled and that their temperature is well-maintained in surgery.”
C. diff a problem
Tucson Medical Center still has work to do in sustaining its improvements, and in further reducing hospital-associated infections, particularly C. diff, officials said. Anderson said the hospital has an ongoing emphasis on hand-washing and stressed that hand sanitizer doesn’t work against C. diff.
If a patient is in isolation because he or she is at risk for C. diff, or already has it, Tucson Medical Center tells nurses and visitors that they must wear gowns and gloves. An audit revealed that rule was being ignored, so hospital officials became more strict about it.
“It’s so important because a cellphone, anything can get contaminated and if it goes out, or if patient families then go to the cafeteria, we just worry about where that goes,” Anderson said. “We really just put our foot down.”
In 2013, the CDC published a report that categorized C. diff as an urgent drug-resistant threat in the U.S. Because overusing high potency antibiotics puts patients at risk for C. diff, Anderson said at Tucson Medical Center there’s a constant evaluation of antibiotic use.
Criticism of penalties
Some critics say that the penalty program for hospital-associated infections is not a fair way to judge a hospital’s level of safety for patients. For one thing, 25 percent of hospitals are always penalized under the current formula, which means that even if they are all good, one quarter are always penalized.
Also, several hospitals that were penalized are highly rated on other matrices. For example, Banner Heart Hospital has a five-star quality rating with the Centers for Medicare & Medicaid Services, yet it finished in the worst quartile in the nation under this year’s hospital-acquired condition reduction program.
Akin Demehin, director of policy for the American Hospital Association, calls the Medicare penalty program “poorly designed policy that results in unfair penalties, especially for teaching hospitals and large hospitals that care for the sickest patients and perform the most complex surgeries.”
The program, which has assessed more than $1 billion in penalties since it began, is in need of reform to more effectively promote improvement, Demehin said. “And we need better measures that more accurately reflect performance on important issues,” he said.
The government did not release an estimate of how much the program will cost penalized hospitals. But an analysis by the Association of American Medical Colleges says the hospitals altogether will pay about $430 million, up 18 percent from $365 million last year.
The public should remember that the data does not take recent improvement efforts into consideration, said Sandra Severson, vice president of care improvement for the Arizona Hospital and Healthcare Association.
The difference in a hospital being penalized and non-penalized can come down to one-tenth of a point, which is an arbitrary point and not a valid measure of safe or unsafe care, she said.
Patient safety
But supporters note that hospital-acquired infections have dropped nationally, which is the ultimate goal of the program.
“It’s important stuff. I think whether you want to complain about the measurement, or say the data is old, who wants to have hospital-associated infections or patient safety problems like blood clots or pressure ulcers?” said Tucson Medical Center’s Anderson.
“When you look at your measurements, it should really be that you don’t want any of those things to ever happen. ... For us, it is so important to patients, but also to our bottom line. In general I think it’s a good program.”
The Kaiser Health News analysis says 241 hospitals nationwide, including Banner-University Medical Center Tucson, were punished all three years of the program. Others include Brigham & Women’s Hospital in Boston; Grady Memorial Hospital in Atlanta; and Northwestern Memorial in Chicago.
“It really is a disservice to the public to dismiss these findings,” said patient safety expert Helen Haskell, a South Carolina resident who founded the national group Mothers Against Medical Error.
“The hospitals are upset because they’ve shown some of the most famous and wealthiest hospitals have safety problems.”
Haskell said the public also deserves to know that large academic medical centers can and do have safety problems — they have young, inexperienced people working there and a lot of turnover, she said.
“Transparency always helps,” she said.
