Should government stop paying for hospital infections?

Pennsylvania is considering taking another very big step in fighting hospital-acquired infections (HAIs): not licensing hospitals that fail to lower their HAI rates. It's a move that worries some pharmacists. "The most effective measures encourage reporting; they don't punish for it," said Douglas Scheckelhoff, M.S., director, ASHP Pharmacy Practice Sections.

The state may even go further, according to Amy Kelchner, spokeswoman for the Governor's Office of Health Care Reform. Next month, the Governor will issue an executive order forming an employers' coalition to study an idea floated in Rendell's original health reform design: "The Commonwealth will, over time, stop paying healthcare providers for care associated with HAIs and medical errors."

Because nearly two dozen states have either followed Pennsylvania's lead in public reporting of hospital infections or are considering it, what happens there about licensing and reimbursement could happen elsewhere. And there are national initiatives examining the issue of tying reimbursement to medical errors.

For example, the Leapfrog Group, a coalition of employers that promotes quality accountability in health systems, is polling hospitals to determine their willingness to not charge for "never events," a National Quality Forum list of medical errors that should never occur. President Bush last year ordered the Centers for Medicare & Medicaid Services to conduct a study on whether Medicare should pay for never events.

According to a report issued late last year by the Pennsylvania Health Care Cost Containment Council, the average hospital stay was about 16 days longer for patients with HAIs than other patients. In 2005, HAIs led to 2,500 deaths and more than $3.5 billion in excess charges, the report said.

Those numbers led the Governor to aggressively address the issue in his proposed health plan, said Kelchner. The law's provision to deny licensing to hospitals failing to reduce HAI rates, if adopted by the legislature-a big if, according to some observers-would make it the first in the nation to use licensing as a punitive strategy for lowered HAIs.

Some R.Ph.s believe such punitive action deters quality improvement. ASHP's board of directors, for example, recently adopted an interim policy that states that although the society supports pay-for-performance (P4P) initiatives when they're "appropriately structured to improve healthcare quality," it opposes P4P programs that "do not support an open culture of medication error reporting."

"Withholding pay for the care associated with medical errors could drive underground the fact those errors are occurring," said Scheckelhoff. "Punitive action is very likely to adversely affect what is reported." That would be particularly unfortunate in Pennsylvania, he said, because the state has made positive strides in addressing HAIs. It was the first state to mandate public reporting of HAIs, in 2004, and remains the only state to publish hospital-level HAI rates on the Internet. Since then, 16 states have passed mandated reporting laws and nine more are considering it.

Another provision of the proposal is specifically supportive of health-system R.Ph.s. It states that the "places where pharmacists are permitted to manage drug therapy are expanded to include academic health centers and group practice settings where the pharmacist is an integral member of the clinical team and has access to the patient's medical records."

Martin Sipkoff is a writer based in Gettysburg, Pa.