Major article| Volume 40, ISSUE 4, P314-319, May 2012

Perceived impact of the Medicare policy to adjust payment for health care-associated infections


      In 2008, the Centers for Medicare and Medicaid Services (CMS) ceased additional payment for hospitalizations resulting in complications deemed preventable, including several health care-associated infections. We sought to understand the impact of the CMS payment policy on infection prevention efforts.


      A national survey of infection preventionists from a random sample of US hospitals was conducted in December 2010.


      Eighty-one percent reported increased attention to HAIs targeted by the CMS policy, whereas one-third reported spending less time on nontargeted HAIs. Only 15% reported increased funding for infection control as a result of the CMS policy, whereas most reported stable (77%) funding. Respondents reported faster removal of urinary (71%) and central venous (50%) catheters as a result of the CMS policy, whereas routine urine and blood cultures on admission occurred infrequently (27% and 13%, respectively). Resource shifting (ie, less time spent on nontargeted HAIs) occurred more commonly in large hospitals (odds ratio, 2.3; 95% confidence interval: 1.0-5.1; P = .038) but less often in hospitals where front-line staff were receptive to changes in clinical processes (odds ratio, 0.5; 95% confidence interval: 0.3-0.8; P = .005).


      Infection preventionists reported greater hospital attention to preventing targeted HAIs as a result of the CMS nonpayment policy. Whether the increased focus and greater engagement in HAI prevention practices has led to better patient outcomes is unclear.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Pronovost P.J.
        • Goeschel C.A.
        • Wachter R.M.
        The wisdom and justice of not paying for “preventable complications.”.
        JAMA. 2008; 299: 2197-2199
        • Saint S.
        • Meddings J.A.
        • Calfee D.
        • Kowalski C.P.
        • Krein S.L.
        Catheter-associated urinary tract infection and the Medicare rule changes.
        Ann Intern Med. 2009; 150: 877-884
        • Rosenthal M.B.
        Nonpayment for performance? Medicare’s new reimbursement rule.
        N Engl J Med. 2007; 357: 1573-1575
      1. Centers for Medicare and Medicaid Services. Hospital-acquired conditions in acute inpatient prospective payment system hospitals. 2007. Available from: Accessed October 7, 2008.

      2. Centers for Medicare and Medicaid Services. Hospital-acquired conditions in acute inpatient prospective payment system hospitals. 2008. Available from: Accessed March 2, 2009.

        • Lindenauer P.K.
        • Remus D.
        • Roman S.
        • Rothberg M.B.
        • Benjamin E.M.
        • Ma A.
        • et al.
        Public reporting and pay for performance in hospital quality improvement.
        N Engl J Med. 2007; 356: 486-496
        • Glickman S.W.
        • Ou F.S.
        • DeLong E.R.
        • Roe M.T.
        • Lytle B.L.
        • Mulgund J.
        • et al.
        Pay for performance, quality of care, and outcomes in acute myocardial infarction.
        JAMA. 2007; 297: 2373-2380
        • Schouten L.M.
        • Hulscher M.E.
        • van Everdingen J.J.
        • Huijsman R.
        • Grol R.P.
        Evidence for the impact of quality improvement collaboratives: systematic review.
        BMJ. 2008; 336: 1491-1494
        • Serumaga B.
        • Ross-Degnan D.
        • Avery A.J.
        • Elliott R.A.
        • Majumdar S.R.
        • Zhang F.
        • et al.
        Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study.
        BMJ. 2011; 342: d108
        • Hoff T.
        • Hartmann C.W.
        • Soerensen C.
        • Wroe P.
        • Dutta-Linn M.
        • Lee G.
        Making the CMS policy for healthcare-associated infections work: organizational factors that matter.
        J Healthc Manag. 2011; 56 (discussion 335-6): 319-335
        • Hartmann C.W.
        • Hoff T.
        • Palmer J.A.
        • Wroe P.
        • Dutta-Linn M.M.
        • Lee G.
        The Medicare policy of payment adjustment for health care-associated infections: perspectives on potential unintended consequences.
        Med Care Res Rev. 2011 Aug 1; ([Epub ahead of print.])
        • Sofaer S.
        Qualitative methods: what are they and why use them?.
        Health Serv Res. 1999; 34: 1101-1118
      3. AHA Annual Survey Database FY 2009. Health Forum, LLC; 2010. Available from:

        • Jha A.K.
        • Orav E.J.
        • Zheng J.
        • Epstein A.M.
        Patients’ perception of hospital care in the United States.
        N Engl J Med. 2008; 359: 1921-1931
      4. Medicaid program; payment adjustment for provider-preventable conditions including health care-acquired conditions. Final rule.
        Fed Regist. 2011; 76: 32816-32838
      5. National Conference of State Legislatures. Hospital and state legislatures: an overview and collection of resources useful for state policymakers. Available from: Accessed May 29, 2008.

      6. APIC. APIC Overview of State HAI Reporting Laws. 2008. Available from: Accessed May 1, 2011.

        • Zhan C.
        • Elixhauser A.
        • Friedman B.
        • Houchens R.
        • Chiang Y.P.
        Modifying DRG-PPS to include only diagnoses present on admission: financial implications and challenges.
        Med Care. 2007; 45: 288-291
        • Meddings J.
        • Saint S.
        • McMahon Jr., L.F.
        Hospital-acquired catheter-associated urinary tract infection: documentation and coding issues may reduce financial impact of Medicare’s new payment policy.
        Infect Control Hosp Epidemiol. 2010; 31: 627-633
        • McNutt R.
        • Johnson T.J.
        • Odwazny R.
        • Remmich Z.
        • Skarupski K.
        • Meurer S.
        • et al.
        Change in MS-DRG assignment and hospital reimbursement as a result of Centers for Medicare and Medicaid changes in payment for hospital-acquired conditions: is it coding or quality?.
        Qual Manag Health Care. 2010; 19: 17-24
        • McNair P.D.
        • Luft H.S.
        • Bindman A.B.
        Medicare’s policy not to pay for treating hospital-acquired conditions: the impact.
        Health Aff (Millwood). 2009; 28: 1485-1493
        • Wachter R.M.
        • Flanders S.A.
        • Fee C.
        • Pronovost P.J.
        Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.
        Ann Intern Med. 2008; 149: 29-32
        • Baum S.G.
        • Kaltsas A.
        Guideline tyranny: primum non nocere.
        Clin Infect Dis. 2008; 46: 1879-1880
        • Stone P.W.
        • Glied S.A.
        • McNair P.D.
        • Matthes N.
        • Cohen B.
        • Landers T.F.
        • et al.
        CMS changes in reimbursement for HAIs: setting a research agenda.
        Med Care. 2010; 48: 433-439
        • Wald H.L.
        • Kramer A.M.
        Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections.
        JAMA. 2007; 298: 2782-2784
        • Kaplan H.C.
        • Brady P.W.
        • Dritz M.C.
        • Hooper D.K.
        • Linam W.M.
        • Froehle C.M.
        • et al.
        The influence of context on quality improvement success in health care: a systematic review of the literature.
        Milbank Q. 2010; 88: 500-559
        • Krein S.L.
        • Damschroder L.J.
        • Kowalski C.P.
        • Forman J.
        • Hofer T.P.
        • Saint S.
        The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study.
        Soc Sci Med. 2010; 71: 1692-1701
        • Lo E.
        • Nicolle L.
        • Classen D.
        • Arias K.M.
        • Podgorny K.
        • Anderson D.J.
        • et al.
        Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
        Infect Control Hosp Epidemiol. 2008; 29: S41-S50
      7. US Department of Health and Human Services. HHS action plan to prevent healthcare-associated infections: prevention—targets and metrics. Available from: Accessed May 1, 2011.

      8. Healthcare-Associated Infection Working Group of the Joint Public Policy Committee. Essentials of public reporting of healthcare-associated infections: a tool kit. Available from: Accessed May 1, 2011.

      9. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN). 2010. Available from: Accessed May 1, 2011.

        • Stevenson K.B.
        • Khan Y.
        • Dickman J.
        • Gillenwater T.
        • Kulich P.
        • Myers C.
        • et al.
        Administrative coding data, compared with CDC/NHSN criteria, are poor indicators of health care-associated infections.
        Am J Infect Control. 2008; 36: 155-164
        • Stone P.W.
        • Horan T.C.
        • Shih H.C.
        • Mooney-Kane C.
        • Larson E.
        Comparisons of health care-associated infections identification using two mechanisms for public reporting.
        Am J Infect Control. 2007; 35: 145-149
      10. Healthcare Associated Infections. 2011. Available from: Accessed May 1, 2011.

        • Krein S.L.
        • Hofer T.P.
        • Kowalski C.P.
        • Olmsted R.N.
        • Kauffman C.A.
        • Forman J.H.
        • et al.
        Use of central venous catheter-related bloodstream infection prevention practices by US hospitals.
        Mayo Clin Proc. 2007; 82: 672-678
        • Saint S.
        • Kowalski C.P.
        • Kaufman S.R.
        • Hofer T.P.
        • Kauffman C.A.
        • Olmsted R.N.
        • et al.
        Preventing hospital-acquired urinary tract infection in the United States: a national study.
        Clin Infect Dis. 2008; 46: 243-250