Path of least resistance: rising MRSA infection rates have health insurers countering with education and pay-for-performance initiatives.
Although Sarabeth Gordon heard news reports about methicillin-resistant Staphylococcus aureus, the stay-at-home mother of three and aspiring novelist from New Orleans never knew the powerful blow a MRSA infection cause until she was hospitalized in 2008 with a community-associated MRSA infection.The infection in her nasal passage caused massive swelling in her face. Fortunately for Gordon, her health plan covered hospitalization, outpatient management and antibiotics.
She's not alone. Each year more than 90,000 Americans are affected by MRSA, according to the U.S. Centers for Disease Control and Prevention. The CDC reports that invasive MRSA infections claim at least 18,000 lives a year--more than the number of AIDS-related deaths.
Those numbers continue to climb, and that's got some health insurers looking at ways to educate members and incentivize hospitals to halt the spread of what some are deeming a global epidemic.
MRSA, also known as the "super bug," is a potentially life-threatening, antibiotic-resistant staph infection.
Usually spread through direct skin contact or contact with shared items or surfaces such as towels or used bandages, the infection typically manifests as skin infections, such as pimples or boils. It can be fatal when it enters the body through scrapes or scratches.
About 85% of MRSA infections occur in hospitals and health care settings, such as nursing homes and dialysis centers. Patients with open wounds, invasive devices such as IVs and catheters and weakened immune systems are at increased risk.
Community-associated MRSA, like that which Gordon contracted, also is becoming more widespread. Schools, workplaces, athletic teams and other community locations are ideal settings for the bacteria to flourish.
About 2 billion people worldwide are believed to carry some form of the common bacterium Staphylococcus aureus, and up to 53 million of them are thought to carry MRSA, according to the pediatric parenting advice Web site www.keepleidshealthy.com.
Although its incidence is on the upswing, it's not a new trend. MRSA was first discovered in the United Kingdom more than 40 years ago.
What's driving the rise? Dr. Tom Ebert, vice president and chief medical officer for Health New England Inc., said although there are new antibiotics today, the new agents haven't kept pace with factors "which drive the development of resistant organisms such as antibiotic overuse, inappropriate use and overuse in animal husbandry."
And as more bugs become resistant to antibiotics, the strains become tougher to eradicate, added Bill Finck, director of network initiatives for Horizon Blue Cross Blue Shield of New Jersey.
Feeling the Pinch
MRSA is becoming a costly problem.
Finck said hospitalized patients with staph infections cost nearly three times as much to treat as patients without such infections.
That, in turn, deteriorates hospitals' profitability, he said.
"The cost to hospitals per infection in New Jersey averages about $9,000 more than non-infected patients and adds about seven and one-half days to the average length of stay," Finck said. With nearly 2 million infections a year, the national cost totals about $15,000 per infection to cure. That adds nearly $30 billion to the cost of hospital care, not including attending physician, post-acute care and other costs, he said.
High-priced antibiotics, such as vancomycin and teicoplanin, used to treat MRSA infections also add to the cost of care.
Health plans have yet to see the big-picture impact on their wallets. That's mainly because up until now it was virtually impossible for plans to track claims related to MRSA due to the lack of a diagnostic code pointing directly to the infection. That's about to change with the creation of a new ICD-9 diagnostic code, unveiled in late 2008, that specifically identifies MRSA, said Dr. Ed Scanlan, medical director for Network Health Plan in Wisconsin.
Dr. Carey Vinson, vice president of quality and medical performance management for Highmark Inc., said because its plan pays hospitals on a case-based reimbursement basis, not per diem," we don't see the cost overruns associated with MRSA complications." But Ebert added that health plans understand that nosocomial infections add considerable cost to care. "If a patient gets an infection, that leads to increased hospitalization costs, morbidity and mortality. So it's in our interest to ensure we reinforce to hospitals things they should be doing to prevent transmission."
Plans on Alert
Some health plans are cracking down on hospitals' protocols around MRSA.
The first line of defense, many say, is sending the message of proper hand-washing procedures--a common violation by some health care workers and visitors. Some industry estimates say in a worst-case scenario, as few as 40% of staff members comply with hand-washing standards, with doctors often being the worst offenders.
Susan Pisano, spokesperson for America's Health Insurance Plans, said health plans are taking what she calls "a traditional approach to issues of concern." They're developing programs and initiatives to propose solutions and then disseminating information about what works and best practices, she said.
Pay-for-performance initiatives are one avenue.
Three years ago, Highmark added MRSA reduction as one of the indications of its Quality Blue hospital pay-for-performance program. "Hospitals define the current problem, and then take steps to do something about it," said Vinson. Hospitals are required to perform surveillance cultures on at least three hospital units--at time of admission to identify known positives and then upon discharge if a patient has been on a unit for more than 48 hours.
That helps determine the community carrier rate for each hospital, he said. "Hospitals then can isolate culture-positive patients and work on efforts to decrease transmission to others on the unit. They can use that information to calculate the percentage of compliance, get a rate-per-thousand patient days of the total number of hospital-acquired MRSA infections, and determine the extent of infections throughout the hospital," he said.
Hospitals identified 4.9% of patients admitted to the hospital as being positive for MRSA who otherwise would not have been identified if not for the program, he said.
Similarly, Horizon also is making hospital best practices part of its MRSA line of defense.
In 2005, the New Jersey-based plan partnered with statewide hospitals and third-party vendor Cardinal Health MedMined Services to create the "New Jersey Infection Prevention Partnership," which facilitates the adoption of hospital-wide electronic surveillance technology and consultative services to reduce time necessary for a hospital infection control professional to detect and treat infections.
Because MRSA can be detected by swabbing the nostrils of patients and isolating the bacteria found inside, all patients admitted to one of the program's participating hospitals or intensive care units receive a nasal swab that's cultured within hours. Hospitals then can isolate patients with positive cultures, and staff can follow proper isolation procedures, said Finck.
Thanks to the program, he said several hospitals have "virtually eradicated" the incidence of MRSA infections.
"And infection control professionals no longer have to play 'infection police.' Instead, they can go to units with actionable data and education to assist leaders, train staff and increase quality of care and patient safety," he said.
Cigna is focusing its attention on avoidable hospital conditions. In 2008, the plan implemented a policy around the conditions, including MRSA. The policy was developed to parallel the Centers for Medicare and Medicaid Services' policy on avoidable hospital events for Medicare patients.
Beginning October 2008, Medicare, in an effort to reduce avoidable injury and infection rates, no longer reimburses hospitals for several types of preventable errors, such as infections from urinary catheters and hospital-acquired injuries that occur while patients are in their care.
"Our policy covers infections such as venous access infections regardless of the agent. It basically says that under certain conditions, payment to a hospital will be reduced as a result of the avoidable hospital condition," said Cigna's Medical Director, Dr. Douglas Hadley. To qualify, conditions must be reasonably frequent, preventable with industry best practices, and specifically identified and coded.
Plans' efforts are paying off.
"We've seen hospitals at least begin to talk the talk," said Ebert. "Many of our larger hospitals are sharing some of their experiences with peer hospitals to report ... the problem."
That's helping slash added costs. Last year, 23 hospitals participating in Horizon's New Jersey Infection Prevention program not only reduced the average rate of infection by 15% and avoided nearly 4,700 infections, but also saved more than $28 million, said Finck.
Health plans are a vital warrior in the fight against MRSA, particularly by helping to drive home the message of ways to reduce its spread.
"Since bugs are winning the antibiotic war, the effort has to be focused on prevention," said Finck.
* State of the Market: A new case of methicillin-resistant Staphylococcus aureus, or MRSA, is diagnosed each day.
* What's Being Done: Health plans recognize the impact MRSA is having on the health care system.
* What Lies Ahead: Carriers are cracking down on hospitals to adhere to proper preventive measures and test patients for MRSA, and educating consumers about the infection.
MRSA Facts and Figures
* MRSA stands for methicillin-resistant Staphylococcus aureus--a type of staph bacteria that's resistant to antibiotics.
* Antibiotics have been used since the 1940s to stop the growth of bacteria.
* A new case of MRSA is diagnosed every day.
* MRSA, like other staph bacteria, can cause a skin infection such as pimples, rashes, abscesses, boils, or what can look like a spider bite.
* Sometimes the bacteria remain confined to the skin but also can burrow deep into the body, causing potentially life-threatening infections in bones, joints, surgical wounds, the bloodstream, heart valves and lungs.
* MRSA affects more than 90,000 Americans annually.
* Those at greater risk include people with weak immune systems, athletes participating in contact sports, young children, the elderly, patients in health care facilities, and prisoners or those who share confined space with others.
* Several well-known athletes recently developed MRSA infections, including NBA All-Star Grant Hill, Toronto Blue Jays outfielder Alex Rios, New England Patriots quarterback Tom Brady, Cleveland Browns tight end Kellen Winslow Jr. and Indianapolis Colts quarterback Peyton Manning.
Sources: Stop MRSANow!; www.staph-infection-resources.com; the Association for Professionals in Infection Control and Epidemiology
Learn More
Cigna HealthCare
A.M. Best Company # 68124 (Cigna Insurance Group)
Distribution: Agents and brokers
Health New England Inc.
A.M. Best Company # 68553
Distribution: Brokers, Commonwealth Health Connector (individual insurance in Massachusetts)
Highmark Inc.
A.M. Best Company # 64010
Distribution: Captive sales force, brokers, direct
Horizon Healthcare Services Inc.
A.M. Best Company # 64022
Distribution: Brokers, benefit consultants, direct
For ratings and other financial strength information
visit www.ambest.com.
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| Author: | Chordas, Lori |
|---|---|
| Publication: | Best's Review |
| Geographic Code: | 1USA |
| Date: | Feb 1, 2009 |
| Words: | 1721 |
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