CMS Changes in Reimbursement for HAIs: Setting a Research Agenda

Patricia W. Stone, RN, PhD, MPH
Principal Investigator and Conference Chair

Grant # R13 HS018099
Title: CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) CHANGES IN REIMBURSEMENT FOR HEALTHCARE-ASSOCIATED INFECTIONS (HAIs): SETTING A RESEARCH AGENDA
PI: Patricia W. Stone, RN, PhD, MPH, Associate Professor of Nursing, Columbia University School of Nursing
Co-PIs: Elaine Larson, RN, PhD, Professor of Therapeutic and Pharmaceutical Research
Sherry A. Glied, PhD, Professor and Chair, Department of Health Policy and Management
Lisa Saiman, MD, MPH, Professor of Clinical Pediatrics, Department of Pediatrics
Funder: Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services
Dates: 3/1/09 - 8/31/09
Funding: $39,450

Co-sponsored by the Columbia University’s Center for Health Policy and Center for Interdisciplinary Research on Antimicrobial Resistance, this prestigious, invitational only conference, took place on April 24, 2009 at the New York Academy of Sciences, bringing together a group of about 30 national experts and researchers who are influential in setting health policy, developing practice guidelines, and providing direction for patient safety and infection prevention and control. These national leaders discussed the potential responses by hospitals and how to best assess the impact of this policy change. The product of the conference will be a white paper articulating the research agenda.

Although this conference was not open to the general public and was by invitation only, information from the conference will be disseminated on this web site as well as through other web sites, announcements, and publications. Please be sure to visit this site in August 2009 for results from the conference.

T. Valuck and S. Glied

MORNING SPEAKERS

T. Valuck

"CMS' Progress Toward Implementing Value-Based Purchasing"

Thomas Valuck, MD, MHSA, JD
Medical Officer and Senior Advisor
Center for Medicare Management
Centers for Medicare & Medicaid Services, Baltimore, MD

Thomas Valuck, MD, MHSA, JD, is Medical Officer and Senior Advisor in the Center for Medicare Management (CMM) at the Centers for Medicare and Medicaid Services (CMS). Dr. Valuck advises CMS leadership on policy issues related to Medicare’s payment systems and quality initiatives, particularly pay-for-performance. In his presentation, Dr. Valuck provided an overview of the program’s goals and the Hospital-Acquired Conditions Payment Provision and Present on Admission Indicator Reporting initiatives.

* Download the Powerpoint Presentation *

T. Horan

"Measuring Healthcare-associated Infections"

Teresa Horan, MPH
NHSN Team Leader, Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention, Atlanta, GA

Teresa Horan, MPH, is the team leader for the National Healthcare Safety Network (NHSN) in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention. Through NHSN, Ms. Horan directs the expansion of the scope of surveillance to include healthcare delivery venues beyond the hospital and adherence to proven patient care practices that prevent infectious and noninfectious complications. Ms. Horan’s presentation provided an overview of the current methods and challenges associated with measuring HAI, including case definitions, metrics, and methods of case finding.

* Download the Powerpoint Presentation *

R.A.Dudley

"Using Incentives to Reduce the Rate
of Healthcare-associated Infections"

R. Adams Dudley, MD, MBA
Associate Professor
University of California, San Francisco, CA

R. Adams Dudley, MD, MBA, is an Associate Professor of Medicine and Health Policy at the University of California, San Francisco. Dr. Dudley’s major research interests include developing measures of quality and efficiency of care, assessing the impact of value-based purchasing by employers and health plans, and the consumer role in value-based purchasing. His presentation focused on the utility of incentives in to improve quality of care and the specific challenges surrounding financial and reputational incentives for HAI reduction, including the difficulties associated with HAI measurement.

Key Questions for Morning Breakout Groups:

What are the key research questions (gaps in what we know related to pay-for-performance and HAI)?
What types of research designs are needed to answer these questions?
What are the important methodological issues that should be addressed (designs, data sources, etc.)?
How are these methodological issues similar/different across hospital acquired conditions (what is infection specific)?
How and when do we measure success (use surrogate endpoints)?

K. Gebbie

AFTERNOON SPEAKERS

I. Nembhard

"Creating an Environment for Learning, Innovation
and Successful Implementation in Organizations"

Ingrid Nembhard, PhD, MS
Assistant Professor of Public Health and Management
Yale University School of Public Health, New Haven, CT

Ingrid Nembhard, PhD, MS, is an Assistant Professor of Public Health and Management at Yale University School of Public Health, Division of Health Policy and Administration, and at Yale School of Management. Dr. Nembhard’s research focuses on organizational learning in health care, with an emphasis on the effects of intra- and inter-organizational relationships, leadership, team learning strategies and project management on quality improvement and clinical outcomes. In her presentation, Dr. Nembhard discussed the challenges to organizational learning, including staff resistance, intergroup relations, leader-workforce interactions, performance measurement and control systems, and resource constraints, and provided several strategies for success: frame as a learning challenge, create learning opportunities for staff, involve frontline staff, encourage leadership that facilitates, and measure and reward effort.

* Download the Powerpoint Presentation *

S. Glied

"Other Payer and Provider Responses to the CMS HAI Rule"

Sherry Glied, PhD
Professor and Chair, Department of Health Policy and Management
Mailman School of Public Health, Columbia University, New York, NY

Sherry Glied, PhD, is Professor and Chair in the Department of Health Policy and Management of Columbia University’s Mailman School of Public Health. Dr. Glied’s presentation focused on the likely reactions of hospitals and payers to the CMS changes to HAI reimbursement, including whether other payers will adopt the CMS rule, whether hospitals will recoup by changing coding behaviors, patient selection, or discharge decisions, and whether the policy will achieve its intended effect.

* Download the Powerpoint Presentation *

Key Questions for Afternoon Breakout Groups:

What are the potential responses by payers, providers (intended and unintended consequences)?
What should hospitals be doing to ensure lower HAI and costs?
What are the potential barriers/facilitators to obtain desired behaviors?
What are the highest priority topics for research to assess the impact of the CMS regulations in relation to HAI? In relation to other hospital acquired infections?
Given the discussion this afternoon, does this change any of the conclusions/discussion from the morning?
What role(s) should executive leaders, unit/team leaders and staff play in change efforts?
What challenges exist to studying implementation efforts in this setting, and how might they be addressed?

J. Needleman

M. Radford

P. McNamara, J. Doyle, D. Scanfeld, D. Heitjan

PLANNING COMMITTEE

Patricia W. Stone, PhD, FAAN (Conference Chair)
Associate Professor of Nursing
Columbia University School of Nursing, New York, NY

Sherry Glied, PhD
Professor and Chair, Department of Health Policy and Management
Mailman School of Public Health, Columbia University, New York, NY

Elaine Larson, RN, PhD, FAAN, CIC
Associate Dean for Research and
Professor of Pharmaceutical and Therapeutic Research
Columbia University School of Nursing, New York, NY

Lisa Saiman, MD, MPH
Professor of Clinical Pediatrics
Columbia University, New York, NY

P. Stone, Conference Chair

CONFERENCE PARTICIPANTS

Mary Ann Baily, PhD
Research Scholar
The Hastings Center, Garrison, NY

Jayasree Basu, PhD, MBP
Senior Economist
Agency for Healthcare Research and Quality, Rockville, MD

Patrick J. Brennan, MD
Chief Medical Officer and Senior Vice President
University of Pennsylvania Health System, Philadelphia, PA

James F. Burgess Jr., PhD
Associate Professor
Boston University School of Public Health, Boston, MA

Stephanie Cameron MSc
Analyst
Congressional Budget Office, Washington, DC

Edward Donovan, MD
Professor of Clinical Pediatrics
Child Policy Research Center, Cincinnati, OH

Joseph Doyle Jr., PhD
Associate Professor
MIT Sloan School of Management, Cambridge MA

Kristine Gebbie, DrPH, RN
Dean
Hunter College School of Nursing, New York, NY

Donald Goldmann, MD
Senior Vice President
Institute for Healthcare Improvement, Cambridge, MA

Denise Graham
Executive Vice President
APIC, Washington, DC

Robert W. Haley, MD, FACP
Professor of Internal Medicine
University of Texas Southwestern Medical Center at Dallas, Dallas, TX

Helen Ann Halpin, ScM, PhD
Professor of Health Policy
University of California, Berkeley, School of Public Health, Berkeley, CA

Daniel F. Heitjan, PhD
Professor of Biostatistics
University of Pennsylvania, Philadelphia, PA

W. Charles Huskins, MD, MSc
Consultant, Pediatric Infectious Diseases
Mayo Clinic, Rochester, MN

John A. Jernigan, MD, MS
Deputy Chief, Prevention and Response Branch
Division of Healthcare Quality and Promotion
Centers for Disease Control and Prevention, Atlanta, GA

Daniel Kao, MD, MPH
Analyst
Congressional Budget Office, Washington, DC

Ramanan Laxminarayan, PhD, MPH
Senior Fellow
Resources for the Future, Washington, DC

Jill A. Marsteller, PhD, MPP
Assistant Professor
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

Nikolas Matthes, MD, PhD, MPH, MSc
Vice President for Research
Maryland Hospital Association, Elkridge, MD

Marci McCoy-Roth
Program Officer
The Pew Charitable Trusts, Philadelphia, PA

Peter McNair, BN, MPH, MHS
Visiting Fellow, University of California, San Francisco and
Palo Alto Medical Foundation Research Institute
Policy Analyst, Department of Human Services, Victoria, Australia

Peggy McNamara
Senior Fellow, Center for Delivery, Organization and Markets
Agency for Healthcare Research and Quality, Rockville, MD

David Meltzer, MD, PhD
Chief, Section of Hospital Medicine
University of Chicago, Chicago, IL

Jack Needleman, PhD, FAAN
Associate Professor
UCLA School of Public Health, Los Angeles, CA

Eli Perencevich, MD, MS
Associate Professor
University of Maryland School of Medicine, Baltimore, MD

Trish M. Perl, MD, MSc
Professor of Medicine
Johns Hopkins University, Baltimore, MD

Martha J. Radford, MD, FACC, FAHA
Chief Quality Officer
NYU Langone Medical Center, New YOrk, NY

Denise Remus, PhD, RN
Chief Quality Officer
BayCare Health System, Clearwater, FL

Chesley Richards, MD, MPH
Deputy Director, Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention, Atlanta, GA

Amy Rosen, PhD
Research Career Scientist
Bedford Veterans Administration Center of Excellence, Bedford MA
Professor, Health Policy and Management
Boston University School of Public Health, Boston, MA

Arjun Srinivasan, MD
Medical Epidemiologist, Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention, Atlanta, GA

Rachel Stricof, MPH
Epidemiologist
New York State Department of Health, Albany, NY

Kathy L. Warye
Chief Executive Officer
Association for Professional in Infection Control & Epidemiology
Washington, DC

D. Remus, A. Rosen, and N. Matthes

E. Larson and I. Nembhard

D. Goldmann

S. Cameron, J. Doyle, and D. Kao

P. Stone and T. Valuck

A. Srinivasan and T. Perl

J. Jernigan and P. Brennan

R. Stricof and L. Saiman

OTHER SUPPORT

S. Clock and B. Cohen

Kristine M. Kulage, MA
Director, Office of Research Resources
Web Designer, CIRAR
Columbia University School of Nursing, New York, NY

Timothy Landers, PhD, FNP
Post-doctoral Fellow, TIRAR
Columbia University, New York, NY

Monika Pogorzelska, MPH
Project Coordinator
Prevention of Nosocomial Infections and Cost-Effectiveness Analysis
(P-NICE) Study
Columbia University School of Nursing, New York, NY

Daniel Scanfeld, MS
Pre-doctoral Fellow, TIRAR
Columbia University, New York, NY

Jennifer Wong-McLoughlin, RN, BSN
Nurse Coordinator
Interdisciplinary NICU Antimicrobial Prescribing (iNAP) Study
Columbia University, New York, NY

Sarah Clock, PhD
Post-doctoral Fellow, TIRAR
Columbia University, New York, NY

Bevin Cohen, MPH
Project Coordinator, CIRAR
Columbia University School of Nursing, New York, NY

Yu-hui Ferng, MPA
Project Manager
Interdisciplinary NICU Antimicrobial Prescribing (iNAP) Study
Columbia University, New York, NY

Sarah Jordan
Study Coordinator
Changing Role of Infection Preventionists (CHAIPI) Study
Columbia University School of Nursing, New York, NY

Y. Ferng and J. Wong-McLoughlin

PROJECT SUMMARY

This application is requesting support for a research development conference to be held in New York City at the New York Academy of Sciences on April 24th, 2009. The aim of this one day conference is to develop a research agenda to assess the impact of the recent changes in the Centers for Medicare & Medicaid Services (CMS) reimbursement policies for hospital associated infections. While this conference is specific to infections, many of the issues and questions that are discussed as well as the resulting research agenda that is developed are likely to be transferable to other hospital-acquired conditions. Framed using the concepts of structure, process and outcomes we will bring together about 30 national experts and researchers who are influential in setting health policy, developing practice guidelines and providing direction for patient safety and infection prevention and control to discuss the potential responses by hospitals and how best to assess the impact of this policy change. Our key speakers include 1) a CMS representative who will provide an overview of the policy changes, the rationale for picking the specific conditions and the expected changes; 2) a CDC representative who will provide an overview of process and measurement issues that are important when considering what research needs to be done; 3) a health economist who will discuss the hospital incentives and potential changes in processes including unanticipated outcomes not compatible with best practices; and 4) an organizational behavior expert who will discuss issues related to structures and processes that lead to positive systematic changes that promote the desired quality outcomes.