University Hospital at the Medical Center.
University Hospital and UT Health San Antonio are forming a nonprofit aimed at increasing access to health care. Credit: Scott Ball / San Antonio Report

The Centers for Medicare and Medicaid have penalized Bexar County’s University Health System (UHS) for a fifth straight year for its high level of hospital-acquired infections and patient injuries. UHS was one of three local hospitals that landed in the bottom quarter nationally in 2018 for such conditions.

Consequently, the federal government will lower a year’s worth of Medicare payments by 1 percent for UHS and the other 799 hospitals cited. That 2019 penalty amounts to a $973,000 loss for UHS, which made $1.4 billion last year.

UHS, along with its ancillary surgery centers and clinics, is among 110 hospitals penalized every year since the penalties were instituted in 2014. The cumulative penalties have cost taxpayer-supported UHS almost $3.5 million, and this year’s penalty will be the biggest one-year loss during the five-year stretch, according to UHS records.

In 2017, penalties cost the organization $798,112, slightly up from $794,230 in 2016; in 2015, penalties amounted to $878,495. While the penalties started in 2014, no fines were assessed until 2015.

“The Centers for Medicare and Medicaid rankings mean 75 percent of the hospitals in the U.S. are doing better at preventing harm to patients than those being penalized by Medicare,” said Lisa McGiffert of advocacy coalition Patient Safety Action Network (PSAN). “As a person who depends on that hospital to provide me safe care, that’s not OK.”

The penalties, created by the Affordable Care Act, represent one of the federal government’s sternest attempts to promote patient safety by providing financial incentives for hospitals that reduce hospital-acquired infections and patient injuries. In Texas, 59 hospitals were penalized out of the 405 evaluated.

UHS said the penalty program uses outdated data and does not reflect improvements made.

“The improvements we have made in the last year or two, the positive results, aren’t being shown in the data used when determining penalties,” said Dr. Emily Volk, senior vice president of clinical services at UHS. “We are concerned about the clinical outcomes for all patients, and have focused our attention not only on those patients who develop those outcomes, but on the leading risk factors that [contribute to] these outcomes.”

Dr. Emily Volk, University Health System Senior Vice President of Clinical Services.
Dr. Emily Volk, University Health System senior vice president of clinical cervices.

The factors considered in the Hospital-Acquired Reduction Program include rates of avoidable infections from central line tubes inserted into veins, colon surgeries, and hysterectomies. Medicare also takes into account the frequency of 14 types of in-hospital injuries, including hip fractures, bedsores, sepsis, blood clots, and post-surgical wound ruptures. These potentially avoidable events are known as hospital-acquired conditions or HACs.

Volk told the Rivard Report that 15 nursing units in the hospital system had zero of one or more hospital-acquired conditions for at least one year, an outcome achieved through initiatives aimed at increasing hand-washing among providers, being more mindful of the use of central lines and urinary catheters, and paying closer attention to how long practitioners are prescribing antibiotics.

“We have more work to do because we would like to see zero hospital-acquired infections across the whole hospital,” Volk said.

While UHS said internal data reflects a more accurate picture of improved hospital-acquired condition rates, McGiffert said hospitals often claim that “old data” is being used as a way to justify poor performance.

“The reason that we are looking at old data is because the system that develops these measures and reports on them is accommodating hospitals to take their time combing through and reporting this data,” she said. “It benefits them to not have the current information right here.”

The financial penalty for low-performing hospitals has long been controversial. The hospital industry has protested the penalties, saying the program’s design creates an arbitrary cutoff for which institutions are punished and which aren’t. The American Hospital Association calculated that only about 41 percent of the 768 hospitals penalized in 2017 had statistically significant higher hospital-acquired condition scores than hospitals not being penalized.

A 2015 study in the Journal of the American Medical Association found that hospitals penalized more frequently by the Centers for Medicare and Medicaid Services (CMS) often have “more frequently had more quality accreditations, offered advanced services, were major teaching institutions and had better performance on other process and outcome measures. These paradoxical findings suggest that the approach for assessing hospital penalties in the [Hospital-Acquired Condition] Reduction Program merits reconsideration to ensure it is achieving the intended goals.”

When discussing these same penalties in 2018, Dr. Bryan Alsip, executive vice president and chief medical officer with UHS, said the penalties “have been controversial across the country because they fall disproportionately on teaching hospitals such as University Hospital, which cares for the sickest and most complex patients in our community.”

In a recent conversation, Alsip said he is careful to not claim “that [UHS is] an academic medical center as an excuse.”

Bryan Alsip, University Health System executive vice president and chief medical officer
Bryan Alsip, University Health System executive vice president and chief medical officer

“Sometimes, being that we are a teaching hospital, we may do a high level of investigation for those patients not only because we are taking care of them, but we are educating our next generation of providers,” and every patient warrants the best quality care, he said, noting that could result in an increased rate of infections.

But McGiffert said that “the measures used are pretty heavily adjusted for teaching hospitals, adjusting scores to take into consideration all these things that teaching hospitals have to do, and amend the score to make them a little bit better than they actually were.”

In addition, McGiffert said, “it is important to make clear to the public that hospital-acquired infection rates [considered when determining penalties] are a small snapshot of the harm that patients experience [at the] hospital.”

PSAN works with a lot of people who lost a loved one due to hospital errors, “including being harmed by prescription drugs, medical devices, surgical errors, and infections not included in what is being considered by CMS when they determine these penalties,” she said.

Not far behind UHS is CHRISTUS Santa Rosa, which is facing its fourth straight year of penalties, and Southwest General Hospital, which is in its third penalty year for high rates of hospital-acquired infections.

Gina Acosta, director of business and physician operations for Southwest General, declined to comment in response to multiple inquiries.

Dr. Kenneth Davis, chief medical officer for CHRISTUS Santa Rosa Health System, said in a statement that “there are [a] number of ways to assess [the] quality of care based on recent performance that offer a better and more current snapshot of CHRISTUS Santa Rosa.”

Davis points to Medicare’s Hospital Compare tool, which ranks hospitals on a five-star rating system based on 57 reporting measures, including patient experience, effectiveness of care, and mortality rates.

“Each year, CHRISTUS Santa Rosa is consistently ranked in the three- or four-star category, highlighting above average overall performance among hospitals in the San Antonio region.”

McGiffert said the Hospital Compare tool is good for consumers wanting to see how one hospital is doing in preventing a certain type of infection to be able to compare it to another, but the score used for Medicare penalties “gives an overall picture of how hospitals are doing on the safety side.”

“As a consumer, the [CMS] penalties are helpful because it gives an overall safety score for a hospital based on infections scores reported on all patients, not just Medicare patients. And that is important for the community to know so they can hold these hospitals accountable.”

Roseanna Garza

Roseanna Garza reports on health and bioscience for the San Antonio Report.