The American Recovery and Reinvestment Act of 2009 authorized $50 million to support states in efforts promoting surveillance and prevention of healthcare-associated infections (HAIs), encourage collaboration, train the workforce in HAI prevention and measure outcomes. Many states that received funding structured their activities around the Department of Health and Human Services National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination.

In March 2010 the Patient Protection and Affordable Care Act established multiple platforms to improve healthcare safety and incentivize hospitals to lower HAI rates. The Act defined the Hospital Inpatient Value-Based Purchasing (VBP) program in which the Centers for Medicare & Medicaid Services (CMS) assess each hospital’s total performance to determine payment reductions that vary by fiscal year (FY). For FY 2017, the VBP program includes payment provisions for surgical site infection (SSI) for colon and abdominal hysterectomy procedures. A hospital is subject to a penalty of up to 2% of its base operating DRG payment.

As of July 1, 2011, the Affordable Care Act prohibits Medicaid payments for the same SSI category of Hospital-Acquired Conditions (HACs) originally established for Medicare in 2008. This category includes SSI following:

  • Coronary Artery Bypass Graft (CABG) - Mediastinitis
  • Bariatric Surgery
    • Laparoscopic Gastric Bypass
    • Gastroenterostomy
    • Laparoscopic Gastric Restrictive Surgery
  • Orthopedic Procedures
    • Spine
    • Neck
    • Shoulder
    • Elbow
  • Cardiac Implantable Electronic Device (CIED) Procedures

Since January 1, 2012, hospitals that are paid under the Inpatient Prospective Payment System (IPPS) have been required to submit SSI data for colon and abdominal hysterectomy procedures as part of the Hospital Inpatient Quality Reporting (Hospital IQR) program in order to receive full potential reimbursement in their Medicare Annual Payment Update. As of FY 2017, those that do not submit all required measures in the Hospital IQR program will receive a one-fourth reduction of the applicable percentage increase in their annual market basket update. SSI data is publicly reported on the Hospital Compare website.

Beginning FY 2015, the Hospital-Acquired Condition (HAC) Reduction Program, mandated by the Affordable Care Act, requires the CMS to reduce hospital payments by 1 percent for hospitals that rank among the lowest-performing 25 percent with regard to HACs. SSI was added to the program in FY 2016 and remains in FY 2017.

The PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program includes a small number of niche cancer hospitals that are exempt from the Medicare PPS. Beginning FY 2015, the program will assess the incidence of SSI following abdominal hysterectomy and colon surgeries, including laparoscopic procedures. Although the quality measures will be public, there is no payment adjustment attached to reporting.

Efforts to improve healthcare safety are made at the clinician level, previously with the Sustainable Growth Rate (SGR) provision per Section 1848(f) of the Social Security Act of 1997. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 ended the SGR formula, moving from a cost-control reimbursement strategy to a quality-focused program. MACRA participation began in 2017 with SSI among one of the reportable quality measures.

This represents highlights of US Legislation regarding the reduction of SSI and is not an exhaustive list.