Medicare Failed to Investigate Suspicious Infection Cases at 96 Hospitals

Some health care centers find ways to “game” the system

The Department of Health and Human Services’ Office of the Inspector General (IG) has found that 96 hospitals reported suspicious data on dangerous infections to Medicare officials, but the agency failed to follow up or examine any of the cases in depth, according to an article on the Kaiser Health News (KHN) website.

Most hospitals report how many infections affect patients during treatment, meaning the infections are likely to be related to the patient’s health care. Each year, Medicare is supposed to review up to 200 cases in which hospitals report suspicious infection-tracking results.

The IG said Medicare should have done an in-depth review of the 96 hospitals that submitted “aberrant data patterns” in 2013 and 2014. Such patterns included a rapid change in results; improbably low infection rates; and assertions that infections nearly always occurred before patients arrived at the hospital.

The IG’s study was designed to address concerns over whether hospitals are “gaming” a system in which it falls to them to report infection rates among their patients. In return, the facilities can receive bonuses or penalties worth millions of dollars. These bonuses and penalties are part of Medicare’s Inpatient Quality Reporting program, which is meant to reward hospitals for low infection rates.

A rigorous review of hospital-reported data is important to protect patients, Lisa McGiffert, director of the Consumers Union’s Safe Patient Project, told KHN.

“There’s a certain amount of blind faith that the hospitals are going to tell the truth,” she said.

And yet there are no uniform standards for reviewing the data that hospitals report, according to Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine.

“There are greater requirements for what a company says about a washing machine’s performance than there is for a hospital on quality of care, and this needs to change,” Pronovost said. “We require auditing of financial data, but we don’t require auditing of [health care] quality data, and what that implies is that dollars are more important than deaths.”

In 2015, Medicare and the Centers for Disease Control and Prevention (CDC) issued a joint statement cautioning hospitals against manipulating infection data. The report said CDC officials heard “anecdotal” reports of hospitals declining to test apparently infected patients so that there would be no infections to report to Medicare. They also warned against over-testing, which helps hospitals assert that patients presented to the hospital with pre-existing infections, thus avoiding a penalty.

In double-checking hospital-reported data from 2013 and 2014, Medicare reviewed the results from 400 randomly selected hospitals––approximately 10% of the nation’s more than 4,000 hospitals. Officials also examined data from 49 “targeted” hospitals that had previously under-reported infections or had a low score on a prior year’s review.

Only six hospitals failed the review, which included a look at patients’ medical records and tissue-sample analyses. Those hospitals were subject to a 0.6% reduction in their Medicare payments. Medicare did not specify which six hospitals failed the data review, but it did identify dozens of hospitals that received a pay reduction based on their reports on quality of care.

The new IG report recommended that Medicare “make better use of analytics to ensure the integrity of hospital-reported quality data.” A response letter from Centers for Medicare and Medicaid Services Administrator Seema Verma said that Medicare concurs with the finding and will “continue to evaluate the use of better analytics … as feasible, based on [Medicare’s] operational capabilities.”

Questions about the truth in reports of hospital infections have percolated for years, as findings have trickled out from states that double-check data, according to the KHN article.

In Colorado, one-third of the central-line infections that state reviewers found in 2012 were not reported to the state by hospitals, as required. Two years later, however, reviewers found that only 2% of central-line infections were not reported.

In Connecticut, a 2010 analysis of three months of cases found that hospitals reported approximately half— 23 out of 48—of the central-line infections that made patients ill. Reviewers took a second look in 2012 and found improved reporting—approximately one quarter of the cases were unreported.

New York state officials have a rigorous data-checking system that they described in a report on 2015 infection rates. In 2014, they targeted hospitals that were reporting low rates of infections and urged self-audits, which found an under-reporting rate of nearly 11%.

Not all states double-check the data, however, which Pronovost said underscores the problem with data that track the quality of health care. He said common oversight standards, like the accounting standards that apply to publicly traded corporations, would make sense in health care, given that patients make life-or-death decisions based on quality ratings assigned to hospitals.

Sources: Kaiser Health News; May 8, 2017; and HHS Report; April 2017.