VAP in ‘Neverland’

In today’s healthcare landscape, everything changes; particularly in the realm of reimbursement. In 2008, CMS moved forward with reimbursement exclusions for what it terms “never events,” at the same time targeting new areas for possible reimbursement denial in the future. In 2009, it put ventilator-associated pneumonia (VAP) on its list for consideration for a flight to Neverland.

In 2011, CMS published a rule stating non-payment policies for provider-preventable conditions and healthcare-acquired conditions, but to the relief of facilities and providers across the country, VAP and other ventilator-associated events (VAEs), were not restricted. The eventual never events identified by CMS were: foreign objects retained after surgery; air embolism; blood incompatibility; stage III and IV pressure ulcers; falls and trauma; catheter-associated urinary tract infections; vascular catheter-associated infections; poor glycemic control; surgical-site infection following coronary artery bypass graft; bariatric and orthopedic surgeries; deep vein thrombosis or pulmonary embolism following total knee replacement or hip replacement, with some exceptions; wrong invasive procedure performed on a patient; surgery performed on wrong body part or wrong patient.

It’s fortunate for hospitals and providers that VAE have escaped payment denials, considering that one VAP case costs a hospital about $40,000 in additional expenses, according to the Society of Critical Care Medicine. Additionally, the society has reported the incidence of VAP to be 22% in patients receiving mechanical ventilation. It also declared the mortality rate attributable to VAP is about 27% and as high as 43% when the causative agent was antibiotic resistant. The yearly fiscal bite VAE exacts on U.S. hospitals is estimated at $1.2 billion.

However there remain rumblings and rumors that VAP could be reintroduced as a never event as reimbursements tighten and performance of VAP bundles make VAP even more “never-worthy” than ever before, i.e. when VAP is truly preventable, it might also be reasonably non-reimbursable.

According to a November 2012 article in NAMDRC’s Washington Watchline, VAP has been high on the Medicare adminstration’s list of preventable complications. But because there was a “lack of a clear definition of VAP and absence of a unique IDC-9-CM code that identified ventilator-associated pneumonia,” as well as a lack of clear understanding as to how effective ventilator management guidelines were in preventing VAP, it was untenable to deny reimbursement at that time. With staunch professional opposition around the inclusion of VAP as a never event and a willingness by professional organizations and the CDC to collaborate on a 2013 Surveillance for Ventilator-Associated Events algorithm (providing criteria for defining VAP as a reportable condition), reimbursement remains stable for now.

A Bullet Dodged
But things often change.

Kevin Johnson, BA, RRT, AE-C, RCP, cardiopulmonary manager at Citizens Medical Center, Colby, Kan., thinks the reprieve could be short-lived. “While I think we dodged a bullet this time around, I absolutely think [VAP] eventually will become a target for non-reimbursement. I am really surprised they took it off of the list because it seems like an easy target for non-reimbursement since it is nosocomial to begin with.”

Johnson, who serves on a committee at his facility that deals with reimbursement issues around COPD, added, “It’s my understanding that CMS can audit as far back as 5 years to get their data, so what we are doing in practice today could very well affect how hard we will be hit when/if they do decide to include VAP as a never event.”

Amesh A. Adalja, MD, FACP, FACEP, University of Pittsburgh, also is wary about the future of VAP reimbursement, noting that third-party payors may take an increasingly dim view on VAP – and the time may come when they do not want to pay for it anymore.

“It hasn’t become a no-pay event yet because VAP has been so tied to the way mechanical ventilation is used and remains an inherent risk,” said Adalja. “Until now, VAP has not fit into the HAI never-event paradigm because it continues to occur simply by virtue of the patient population that ends up on ventilators – very sick patients at very high risk are often those who require the ventilator. But that said, I do think that there will be further discussions on how VAP will be paid for in the future because it is something that should not happen.”

A Need for Caution
Brent Holland, BSRT, RRT-NPS, Mission Health, Asheville, N.C., is optimistic about continuing reimbursement. “I think VAP will never be considered a never event; there are too many variables that go into it. In some situations, it’s caused by viruses or bacteria or other pathogens that are not even hospital-related. Also because of the new criteria, I think the diagnosis of ventilator-associated pneumonia will go down. If they make VAP a never event, hospitals would likely say the fever is caused from something else, and the diagnosis of VAP simply would not be made.”

Steven Koenig, MD, FCCP, director of pulmonary, respiratory and critical care, and sleep medicine at St. Claire Regional Medical Center, Morehead, Ky., offered a cautious perspective. “It will probably be a reality at some point, but the move to deny payment for VAP will have to be done carefully with many considerations taken into account,” he said.

“The reality remains that within a population of sick, critically ill, hospitalized patients – some with predisposing factors such as difficulty swallowing, for example — VAP will occur in some cases. Even if providers are doing all the right things – according to evidence-based practices – some patients will still get VAP,” he maintained. He also said there should be no monetary penalty for those providers and facilities that obtain the optimum evidence-based standard of care, regardless of the VAP outcome.

Unbundling VAP Bundles
The larger discussion necessarily puts a stronger spotlight on the various components of VAP bundles to see which are driving improvements in VAE rates and which are not.

“VAP bundles have decreased the rate of VAP, but the question is which portions of those bundles are the most high-yield and can the bundle be un-bundled to find out precisely what works and what doesn’t?” said Adalja. “We’re seeing trials now to determine what components make these bundles the most efficacious as possible. All the components make sense and all are biologically plausible. But when you put them into a critically ill patient with a lot of other things going on, some of those effects may wash out. We need rigorous trials to determine the cost-benefit analysis and understand the viability of various strategies.”

Koenig said it is only when those optimum care parameters are defined that care providers can be assured they are doing everything possible for their patients. “We can’t judge what ‘should;’ be some on things that just make sense on a gut level,” he said. “We need to know what steps have been proven in literature to prevent VAP. We must all adopt those best evidence-based practices and document the steps we take to prevent VAP in a patient. If some step is not taken, due to contraindications in a patient for example, that rationale must be documented as well.” In short, Koenig made the point that when all of the preventive efforts have been taken, and VAP still occurs, it should be a trigger for payment. But he reprised his prior prediction: “In time, will we see payors move toward non-reimbursement? Yes, I believe we’ll be seeing that.”

When ADVANCE contacted CMS for a comment on current thoughts about future changes in VAP/VAE reimbursement, an agency representative responded, “What is VAP and what is VAE?” While it can be chalked up to that staffer’s unfamiliarity with acronyms, one might also feel as if VAEs have already been philosophically shipped off to some no-man’s (read: no-pay) land. Only time will tell.

Valerie Neff Newitt is on staff at ADVANCE. Contact: [email protected]

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