Nine Chicago hospitals ranked among the nation's worst on new measures of infection rates and other patient injuries, drawing federal penalties and raising questions about the way the hospitals are assessed.
Northwestern Memorial Hospital and other prominent academic hospitals were among those with the highest rates of conditions — from bedsores and reopened wounds to catheter infections and broken hips — that are considered avoidable, according to newly released federal data. In Illinois, 27 hospitals — about 1 in 5 that Medicare examined — will be penalized.
The federal government is withholding 1 percent of Medicare payments for 721 general hospitals reporting the highest rates of "hospital-acquired conditions." The penalties, which will be assessed in the fiscal year that runs through September 2015, were created by the Affordable Care Act to improve patient care and save the federal government and taxpayers money. The Centers for Medicare and Medicaid Services estimates the reductions will total $373 million next year.
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"We know some of the procedures we do — heart transplants or resecting cancerous portions of the esophagus — are going to be just more prone to having some of these adverse events," said Dr. Atul Grover, chief public policy officer of the Association of American Medical Colleges. "To lump in all of those things that are very complex procedures with simple things like pneumonia or hip replacements may not be giving an accurate result."
Medicare judged hospitals on three measures: the frequency of central-line bloodstream infections caused by tubes used to pump fluids or medicine into veins; infections from tubes placed in bladders to remove urine; and rates of eight serious complications that occurred in hospitals, including collapsed lungs, surgical cuts, tears and reopened wounds and broken hips. Hospitals were ranked on a 10-point scale, with penalties assessed against institutions with a total score above 7. Those hospitals make up the quarter of hospitals that Medicare assessed as having the highest rates of hospital-acquired conditions.
The penalties come as the hospital industry is showing some success in reducing avoidable errors. A recent federal report found that the frequency of mistakes dropped by 17 percent from 2010 to 2013, an improvement U.S. Health and Human Services Secretary Sylvia Burwell called "a big deal, but it's only a start."
In Illinois, Northwestern Memorial Hospital, the University of Illinois Hospital, Rush University Medical Center and the NorthShore University HealthSystem hospital in Evanston are among those that will paya penalty.Northwestern Memorial, which had the worst score in Chicago and the third-worst in the state, will lose $1.5 million in Medicare reimbursements in 2015, a hospital official said.
academic hospitals also tend to treat patients with complex conditions that often make them more vulnerable to infections caused by catheters, said Dr. Gary Noskin, Northwestern's chief medical officer. Doctors at Northwestern are using fewer catheters to reduce the likelihood of infections. But the rating system doesn't reward that strategy with a better score: with fewer catheters, each infection is weighted more heavily, Noskin said.
"By doing the right thing and eliminating catheter incidents," Noskin said, "you made yourself look 10 times worse."
Rush University Medical Center will be fined $1.7 million out of an annual budget of about $1.6 billion, a spokesman said. A spokeswoman for the University of Illinois Hospital said it didn't know what its fine would be.
The scores are based on data from mid-2011 through 2013 and do not reflect improvements the hospitals have made since then, hospital representatives said.
Representatives of several hospitals said they have improved their infection rates. Northwestern reduced catheter-related infections by 42 percent early this year. U of I's hospital has reduced bloodstream infections by 44 percent and urinary tract infections by 42 percent since 2013. During the same period, Rush University Medical Center reduced hospital-acquired bloodstream infections by 36 percent and catheter-associated urinary infections by 55 percent. OSF St. Anthony Medical Center in Rockford, which had the worst score out of 125 Illinois Hospitals, said it has reduced hospital-acquired infections by 50 percent during the past two years.
"The bottom line is they have made substantial progress, (but) they can still end up on the list," said Illinois Hospital Association spokesman Danny Chun.
The association also raised concerns that the scoring system unfairly penalized hospitals serving low-income populations.
Stroger Hospital, part of the Cook County Health and Hospitals System that serves low-income patients on Chicago's Southwest Side, scored just poorly enough to have its Medicare payments docked. It will lose $100,000 in payments, a relatively small hit to its budget.
"We treat some of the sickest patients, many of whom lack insurance and access to care and as a result only present when their condition has deteriorated so badly they can no longer tolerate it," the hospital system said in a statement. "We also see a high rate of trauma and high-risk surgeries. These complex cases often lead to complex procedures increasing risk for complications."
Representatives of some of the state's smallest hospitals said their scores also were unfairly calculated.
Categories in which Richland Memorial Hospital in south central Illinois performed well were not included in its final score because the hospital had too few patients with catheters, CEO David Allen said.
"We believe the calculation methodology is flawed and penalizes smaller and lower-volume institutions across the country," Allen said.
Sarah Bush Lincoln Health Center, a small hospital in Mattoon in central Illinois, will lose $223,000 in Medicare reimbursements but received Medicare bonuses based on other measures. Chief financial officer Dennis Pluard said, "We come out $139,000 in the positive."
"One incident can jack up our rate because we have a low denominator," Hildebrandt said. "Our performance in (bloodstream infection rates) is excellent and has been for many years. I think the scoring needs some re-evaluating."
Improving hospital-acquired condition rates has been a priority for the hospital system for at least the past five years, said Dr. David DiLoreto, Presence's chief clinical officer. The hospital uses high-tech telemedicine technology to monitor intensive- and critical-care units to make sure standardized checklist procedures are followed.
Presence's best score, a 2.6, went to Presence Resurrection Medical Center in Chicago — the second-best-scoring hospital in the city — and its worst was its Evanston hospital, Presence St. Francis Hospital, with a score of 6.3.
"We've been self-monitoring our performance around health conditions," DiLoreto said. "We set goals years ago for reducing these events further. In many cases the goal is zero, to completely eliminate them."
The federal Agency for Healthcare Research and Quality found that the biggest decreases in errors among those it studied occurred in the two categories of infections Medicare used in setting the penalties. Central-line-associated bloodstream infections decreased by 49 percent and catheter-associated urinary tract infections dropped by 28 percent from 2010 to 2013. By contrast, pneumonia cases picked up by patients on ventilators that help them breathe — a condition not covered by the new penalties — decreased by only 3 percent during the same period.
Some of the errors on which the Medicare penalties are based are rare compared with other mistakes the government tracks. For instance, the Healthcare Research agency estimated that in 2013 there were 760,000 bad reactions to medicine that controls blood sugar in diabetes patients but only 9,200 central-line infections. Infections from tubes inserted into urinary tracts are more common — the agency estimated there were 290,000 in 2013 — but those infections tend to be easier to treat and less likely to be lethal.
The new penalties are harsher than any previous government effort to reduce patient harm. Legally, Medicare can expel a hospital with high rates of errors from its program, but that punishment is almost never carried out, as it is a financial death sentence for most hospitals.
Hospitals complain that the new penalties are arbitrary, since there may be almost no difference between hospitals that are penalized and those that narrowly escape penalties.
The infection penalty program is the third of the federal health law's major mandatory pay-for-performance programs. The first levies penalties against hospitals with high readmission rates, and the second awards bonuses or penalties based on two dozen quality measures.
This year, Medicare has already fined 2,610 hospitals for having too many patients return within a month of discharge.
Now that all three programs are in place, the worst-performing hospitals will be at risk of losing up to 5.4 percent of their Medicare payments.
"The data may not always be what it seems to be on the surface," said Cathy Grossi, the Illinois Hospital Association's vice president of health policy and regulation. "The good news in all of this is we're trying to change culture and make hospitals a safer place."
This story was produced in partnership with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Hirst and Venteicher are Tribune staff reporters. Rau is a staff reporter for Kaiser Health News.
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