How the Affordable Care Act combats preventable hospital infections

As the Supreme Court deliberates the Affordable Care Act, Americans should take a closer look at the commonsense reforms embedded in the law, including those that strengthen public health. Fixation on the law’s individual mandate has overlooked the law’s very important benefits for public health.

Lost amid the rhetoric about individual liberty is the public interest and common good of protecting all Americans from the costly and deadly menace of preventable infections.

Some wildly popular protections in the law, such as keeping children up to 26 on parents’ policies, barring insurance cutoffs for the sick, and ending co-pays for preventive care, have begun to gain the appreciation they deserve. But press coverage of how the law broadens the healthcare risk pool in order to lower overall costs — the so-called individual mandate — has disregarded the law’s focus on a responsibility all Americans share and have a stake in: stopping epidemics and fighting disease.

Foes of the law have failed to spell out how they would solve the public health challenges that the law tackles head-on. The federal law contains important tools for frontline providers to fight epidemics and face accountability. It also arms consumers with information to make decisions about where we seek care and how to avoid common infections.

One rampant form of infection, Clostridium difficile, or C. diff, results in more than 25,000 deaths each year and costs our healthcare system billions. Two years ago this month, my mother Peggy Lillis, an otherwise healthy kindergarten teacher in Brooklyn, N.Y., came down with what she believed was a stomach flu. Having never heard of C. diff, she assumed she picked up a bug from a student and didn’t fret. Six days later she was dead from toxic megacolon, the result of a virulent C. diff infection (CDI).

Irregular disclosure standards by healthcare providers and uneven state reporting and enforcement rules have made the number of infections and deaths like my mom’s hard to measure. Even in cases where it kills, C. diff often still doesn’t get cited on death certificates.

Against this backdrop, the Affordable Care Act contains strong incentives to measure uniformly, report, and counteract the public health crisis of C. diff and other healthcare associated infections. Building on previous reporting mandates from the Centers for Medicare & Medicaid Services, the Affordable Care Act creates a uniform online reference for the public to check the prevalence of healthcare associated infections at local hospitals and make our healthcare decisions accordingly. This tool alone is a significant advance.

The law also reflects sound logic and a basic sense of fair play in considering rates of infections in reimbursement rates to healthcare providers. By tying federal dollars to low incidence of healthcare acquired infections, the Affordable Care Act finally places the economic incentives where they belong.

I doubt most Americans realize that the very healthcare facility where your grandmother might contract C. diff or a multi-drug resistant staph infection (MRSA) can also charge Medicare for the treatment set in motion by their lax hygiene standards. The average cost to treat such an infection is nearly $14,000. Imagine bringing your car to a mechanic for a brake repair, only to have the transmission damaged, and get charged for both.

Such outrages have an overdue cure in the policy its critics label “Obamacare.” The Affordable Care Act, once fully implemented, would replace a status quo where economic incentives regarding healthcare associated infections are fatally misaligned with one driven by patient safety and accountability.

The stakes for our shared public health are much greater than any partisan bickering. Healthcare associated infections like C. diff are a growing threat to American lives and the economic stability of our healthcare system. Striking down or repealing the Affordable Care Act would put at grave risk the gains prompted by the law in reporting, tracking, and combating the epidemic of infections.

Even if they resist the opportunity presented by the Affordable Care Act to expand coverage to more Americans, or reject its individual mandate, opponents of the law cannot escape their own interest in a strong health system that mobilizes every available resource, including an informed populace, to combat epidemics.

Calls for scrapping the law in the political arena, or banter about broccoli in debate about its fate, ignore the focus on public health and saving lives reflected in the law. Especially in the absence of a concrete and comprehensive plan to replace it, losing the Affordable Care Act would reverse major progress in the fight to prevent disease. All Americans–candidate or voter, youth or senior–share an obligation to the hundreds of loved ones like my mother who suffer or die each year from C. diff to accurately track, measure, and combat this public health crisis to the fullest and best of our ability.

Christian John Lillis is co-founder and director, The Peggy Lillis Memorial Foundationthe first national organization dedicated to reducing and eradicating Clostridium difficile infections, or CDIs, through education and advocacy.

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  • westeasterly

    Are you actually suggesting hospitals WANT patients to get C. diff so they can bill for it?  That they promote “lax hygiene standards” to get rich?  And that the only solution is more government intrusion in healthcare?  I like that you choose to use the words “incentive” and “encourage” rather than what we’re actually talking about- force and punishment, even when the hospital may not even be responsible.  Certainly C. diff is a hospital “associated” infection, and that some cases are indeed preventable through careful hand hygiene.  But show me a single hospital in the US that doesn’t preach hand hygiene constantly, and require that every employee receive pre-employment, plus yearly training on this very issue.  Show me a hospital that doesn’t have special procedures in place for handling C. diff positive patients…procedures that are observed from physician, to nurse, to hospital janitor (not to mention providing free patient family education).

    What we’re left with is some cases of preventable infection, and many cases of completely UNpreventable infection that we’re supposed to trust the government to differentiate between.  A sizable percentage of the US population is colonized with C. diff, and as a result, the pathognomonic presentation for C. diff colitis is a patient who has recently received antibiotics.  Who is likely to be receiving antibiotics?  That’s right, hospital patients!  The idea that the hospital should be considered at fault, or that the government (who may be footing the bill) is going to make an honest and carefully considered decision is completely beyond the realm of reasonable.  The government is great at instituting fines, penalties, and fees, but has always been very poor at making wise decisions.  Sometimes treating one life-threatening problem causes another.  This is more like penalizing a mechanic because he fixed a car that was then used in a DUI accident.  Show me a car that is susceptible to infection and I’ll buy your vehicle repair metaphors….  

    While I do think infection reporting is valuable to those who can use the information, it’s simply not valuable to the general populace as you suggest.  What do you expect Joe the mechanic to do with the knowledge that some people in his city have C. diff?  (hint, they do.)  Observe good hand hygiene?  I’m pretty sure he’s already aware of that (from kindergarten, no less).  Not that he’s logging into government websites to track statistics in the first place…..  I hope your organization is successful in promoting awareness about C. diff, but using the blind hammer of government force is always a poor choice, for any issue. 

    • caduceusblogger

      Christian I am very sorry for your loss. But I must agree with many of westeasterly’s points. While many infections are preventable simply punishing hospitals for all of them is not the answer. It would only create a new set of problems, perhaps hospitals would be loathe to treat anyone with an infection? What would happen to all the employees who saw the patient before they were diagnosed, should they all get tested and treated for C. Dif? How far can we take this?

    • overdoneputaforkinit

      Hospital infections rates should be reported to the public. Rather, all adverse events should be tracked and reported by an independent third party organization. We are constantly being told that our for-profit private medical system is the best in the world. But it isn’t. Our private medical system does not follow the rules of a free market system in which the consumer has some basis on which to make a choice between competitors. In our much vaulted health care system, all it’s competitors try to look the same as each other by blocking public access to their performance data. Meanwhile over 100,000 people needlessly die from medical errors each and every year. And that number is not decreasing because there is no real competition in the medical marketplace. The industry is not motivated to improve because individual medical businesses collaborate to protect each other by keeping all adverse event and infection rates hidden from the paying public.

      • westeasterly

        You said it yourself; data reporting is poor.  Yet you cite a number for medical error deaths as though it’s some hard fact that supports your cause.  At least be consistent.  Estimates are just that; the true number may be higher or lower, but what is universally true is that quality improvement is something that is taken very seriously by medical professionals.  The vast majority of medical research performed by physicians is aimed at improving patient outcomes (which drug is better, which technique is more effective, which treatment provides better survival, etc.).  Whether a behemoth of inefficiency and waste (i.e. the US government) can bring about more effective change…well, that’s a subject in and of itself.  

        That said, I agree with some of your observations.  Lack of competition.  Lack of consumer choice.  Lack of transparent and competitive pricing.  These all boil down to a simple truth: lack of a free market.  We do NOT have a free market in healthcare, and this has only gotten worse overtime.  There isn’t a single aspect of healthcare delivery that the government hasn’t meddled with; the very notion that a free market exists in healthcare today is an insult the entire concept of the free market.  There’s this fear out there that “free market” equates to uncontrolled greed, and while there are players in the healthcare market motivated by greed, the core of the medical profession is physicians who have dedicated their entire lives on planet earth to serving their patients.  Many hospital administrators are physicians themselves, and even those which aren’t, ultimately have little say in how their physicians operate.  To suggest that there’s some grand conspiracy to ring the cash register to the detriment of patient care is simply out of touch with the day to day delivery of healthcare.  Even for those motivated by greed, the best way to make the most money is to be the best at providing healthcare.  Dead patients pay their bills much less frequently than live ones.

        A perfect example of how healthcare delivery can be improved in the absence of government interference is the Joint Commission.  This is a completely voluntary, non-profit organization that sets a high bar for hospitals in order to obtain their certification.  It’s completely voluntary, yet costs hospitals a tremendous sum of money to comply with.  Most hospitals get this certification anyway.  It’s the exact opposite of everything you make hospitals out to be.  It’s a system-wide scrutiny of almost every aspect of the hospital, and most importantly it’s based upon evidence and experience.  It’s a way that a hospital in Alaska learns from a mistake in a hospital in Florida.  It’s a way of implementing new research about patient safety techniques nationwide.  And, most relevant to this article, it’s why there’s a unified system in place for how to deal with C. diff infections.  This is all done without a single law being written.  There certainly is room to grow as new opportunities for safety are identified, but this whole notion that we can call upon the federal government to swoop down from on high and solve all our problems is the stuff of fantasy land.

        • overdoneputaforkinit

          You misread my comment. I never wrote that data reporting is poor. I wrote that the data is not made available to consumers who need to have some basis to make a decision among medical providers. The reality is, our medical system is a for-profit medical socialism. There is no competition because the entire medical industry has morphed into a single massive entity. Our medical system is just like a wasteful government program, and it sucks 17% of our GNP, the highest in the world. Other countries with “socialized” medical systems are more efficient and according to many reports, deliver better care with better outcomes and fewer adverse events. Compared to those socialistic systems, our physicians have a long way to go to improve. But I will repeat my basic message: We do not have a competitive medical system that follows the rules of capitalism. We have the worst inefficiencies of capitalism and communism combined. No amount of hard work and hopeful attitudes on the part of many physicians will fix the problem. They are preserving their jobs while working within a system that will not tolerate anyone rocking the boat. The problem will only get worse. Part of the problem is the needless complexity and inefficiency of our private insurance system. Part of the problem is the absolute loyalty anyone within the system must have toward the collective medical system. No change is possible from within while that is true.

  • karen3

    Um, aint gonna work if Medicare refuses to actually impose penalties.  Which is exactly what is happening now.  Drink some more Kool-aid.

  • MarcGarfield_DPM

    I vote to start posting everyone’s traffic records on well lit, large font sign on the roof of everyon’e car.  Then we will know who not to drive next to, and there will be no more traffic accidents. 

    • VanessaObRN

      Weak analogy.  The offending driver often dies or is injured from the very accident he caused.  Not so the healthcare worker.

      • MarcGarfield_DPM

         You completely miss the point.  The Analogy is that neither rule is a good idea, neither would protect you, both are a distraction, both employ new rules to stop accidental incidents that cannot be controlled beyond the proper training and due diligence that already occurs ( you are not safer because the rule exist) and in both circumstances only the entities that already care about their standards and reputations would comply. 
        Think about this, if a great hospital had a horrible outbreak of Listeria.  As you request they post their offense on a billboard outside their hospital.  As long as the posting is required no one goes to the hospital.  The hospital shuts down and next you get down to one or two hospitals that will eventually suffer the same misfortunes, but now you have few choices because the government regulations have run the alternatives out of business.  Now there is less incentive to improve standards because there is no competition. 
        Increased regulation works when you set reasonable standards for all entities to follow.  They fail with ideas like this that take something that can never be fully prevented and trying to pretend that if we had more rules, C. Diff and MRSA would be eradicated. 
        C. diff is best addressed by prompt stool cultures and toxin assays on patients on antibiotics and communication between nurses, patients and doctors regarding symptoms.  No one is sacrificing sterility and patient safety for profit or expediency.  These infections will happen even you make 1000 more rules.  The rules unfortunately just complicate how we deal with the incidents.  PPACA, HIPAA and ARRA/MU provision is the pinnacle or such bureaucratic interference. 
        It needs to stop! We need to all get back to doing what we do best without a government rule defining how we do it!!

        • VanessaObRN

          “You completely miss the point.”

          and your hyperbolic example was on point?

          “As you request they post their offense on a billboard outside their hospital”

          Where did I request that?

          “We need to all get back to doing what we do best without a government rule defining how we do it!!”

          Fine, but we still need some transparency.  Being a nurse for 25 years, I know how easily preventable mistakes can be swept under the rug. And I’ve seen the aggregious results.  Hospitals know who the few bad apples are that cause most of the problems, but turn a blind eye.  The public can’t tap into insider information, like you and I, to know the track record of caregivers and hospitals before making informed medical choices.

          • MarcGarfield_DPM

             So if you are not as blatant as posting a billboard, then the rules on reporting and transparency will be lost in the deluge of reporting and transparency that already exist.  This is why OR “time outs” were found to be ineffective.  They started out being a verification of site and procedure, then everyone else piled there concerns in, so that before I could fix a bunion, we have to review fire hazards and sponge counts.  Eventually, there are so many things to review, that it is done mechanically and humans quit paying attention. 
            Again laws cannot single out these micro issues.  Common sense antiseptic practices are needed.  C diff happens, it does not hide in hospitals, it takes advantage of a compromised host with a disruption in normal gut flora.  We are not likely to reduce C diff rates beyond what is done out of common sense.  So let’s train nurses and doctors to be aware of diarhea, screen appropriate patients and treat them promptly.  Stop, adding forms, rules and reporting so that treating patients get’s lost in a slurry of PQRS, MU, JCOH and other lists of rules, regs and forms we are supposed to complete.  When these additional ACA rules are lost in the slurry, we won’t remove them, we will just add more rules. 

  • Karen Sibert MD

    You have my deepest sympathy in the death of your mother. Unfortunately, the PPACA will do nothing but create more layers of bureaucracy that are already raising the cost of health care exponentially and imposing further burdens on hospitals and physicians.  Clearly, better reporting and data helps us understand infection rates as well as everything else. But the great advances in preventing many medical complications such as central line infections have come from scientific study and changing clinical practice, instituted by physicians and hospitals, not by mandates from above. Many of the clinical guidelines that were thought wise several years ago–such as aggressive beta blockade and tight glucose control–have been shown to do more harm than good. Science solves medical problems; more government control and interference does not. Kathleen Sebelius won’t be at your side when you get sick.

    • Christian John Lillis

      Hi Karen –

      Thanks for your response and kind words about my mother. Obviously we disagree about the impact the Affordable Care Act will have. My in-laws are physicians, so I am very empathetic to any additional burdens place on doctors. Further, I agree that smart science leading to changed clinical practice is critical to healthcare advancement and patient safety.

      Where we disagree is what the government’s role should be in public health issues. I’m sure you know that at least 25,000 Americans (an extremely conservative number) die each year of C. diff infections and tens of thousands more do so from other HAIs. To my mind, any country that can split the atom and put the first man on the moon can do better. Minimally, hospitals and other facilities can do a much better job of hand hygiene, terminal sanitation and sharing risk factors with patients so they can make informed decisions.

      I welcome physicians leadership on this and other safety issues. Certainly, there are many fine physicians and healthcare workers are, indeed, providing great leadership but when average hand washing compliance is less than 50% in many hospitals, incentives are dangerously misaligned.

      I would welcome your further thoughts on how we can work together for everyone’s benefit.

  • Howie

    Keeping my politics aside  this was certainly an interesting read.

    • Christian John Lillis

       Thanks, Howie. I’m glad that it inspired such a vigorous debate. One goal of the piece was to get us talking about parts of ACA that I felt were being completely ignored.

  • katerinahurd

    Do you think that ACA focusses more on peventative medicine, and thus, limits hospitalizations.

    • Christian John Lillis

       I think there are efforts to put a priority on overall prevention but it’s too soon to tell how effective they will be. In this case, there’s enormous potential to prevent hospital associated infections to save lives and money.

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