Over the course of September, the annual recognition of Sepsis Awareness Month, we acknowledged all of the work being done by clinicians around the state to educate, prevent and treat this deadly complication from infection. We listened to the challenges facing survivors, and we remembered those lost to sepsis.
Sepsis is a severe reaction of the body to an infection, and is one of the most deadly and costly diagnoses in the United States. Despite advances in identification, diagnosis and treatment, it remains a pernicious threat to good health. There is consensus that early identification and treatment dictates patient outcomes. And we are still learning about the long-term effects it has on survivors.
Our clinical quality improvement teams conscientiously focused on recognizing symptoms and acting appropriately before sepsis leads to severe complications or even death. This is complicated by the fact that sepsis can rapidly develop from an issue as innocuous as a scratch. Hospitals and other health care providers studied and implemented bundled interventions to standardize response every time sepsis is suspected. The risk of not taking potential sepsis cases seriously is death.
But now, there is a new challenge facing health care providers in the fight against sepsis.
Some of the largest private health insurance companies in the state — and nation — are following UnitedHealthcare’s lead in implementing new payment audit policies that do not support early sepsis detection and intervention. Payment, payment audit policies and regulations are not always aligned with what we are trying to achieve in health care today. This is a prime example of policies at odds with what is generally accepted as good health care practice.
Incentivizing a delayed reaction
The UnitedHealthcare policy says that, after a hospital provides care to a patient and sends the claim to the insurer, clinical claims reviewers will only recognize that sepsis was present and that treatment was appropriate when it meets the Sepsis 3 definition. Sepsis 3 is defined as life-threatening organ dysfunction that may be accompanied by septic shock, further increasing the risk of mortality than with sepsis alone.
Time is of the utmost importance when identifying and treating sepsis, so much so that the Sepsis Alliance promotes the acronym TIME (Temperature, Infection, Mental Decline, Extremely Ill) to educate the public on early symptoms of sepsis. While health care professionals always prioritize the needs of their patients, this means that the new payer policies are incentivizing a delayed reaction to these warning signs.
There are additional reasons why this new policy is concerning:
- The definition of Sepsis 3 has yet to be accepted by the Centers for Medicare and Medicaid Services, the largest payer in our nation. It was created as a tool for judging potential mortality, not for diagnosis purposes. CMS uses the Sepsis 1 definition for diagnosis, which was created as a best practice for clinical treatment. New policies like UnitedHealthcare’s open the door for conflicting protocols and confusion in documentation, adding to an already fragmented and burdensome process.
- The Sepsis 3 definition reduces the number of ways to code sepsis in health records from three codes to two. In addition to paying providers, diagnosis codes are used to study trends in health care and used in quality improvement efforts. Additionally, some cases of sepsis will not be included at all in the data because they no longer fit the stricter definition. Our data will not be as specific or complete when we look at health care claims, making it more difficult to understand the severity of sepsis and whether quality interventions work.
- The Sepsis 1 definition, in partnership with the standard bundle of care, reduced mortality and hospital readmissions for all sepsis cases. This is based on many years of data, study and evaluation, which is not available for Sepsis 3.
- Our entire health care system is shifting toward value-based care and population health. Both of these concepts center on keeping people healthy and intervening before a medical issue requires intensive resources. Shifting the focus of payment and payment audit policies to when there is an indication of organ failure means financial resources are being targeted by the payer only when the patient is in imminent danger and requires a much higher level of care — where is the value in that?
We estimate that this change in audit policy could immediately affect roughly 600 UnitedHealthcare customers in New Jersey in a year, at a payment reduction of $7.3 million. If all other payers take up the same policy, we project as many as 9,000 inpatient cases annually would be held to the non-consensus, Sepsis 3 definition so that an estimated $107 million can be saved. We, like sepsis survivors and families who have lost loved ones to sepsis, say that is not a “savings.”
We are all sensitive to bending the cost curve in health care, but unilateral policy decisions that delay what is most beneficial for patients — that puts their lives at risk and contradicts best practices and a culture of health — are a step in the wrong direction. Promoting good preventive strategies and public education is beneficial to both payers and providers in achieving the common goal of saving lives.
We ask that health insurers halt this misguided policy until all parties come to the table to agree on best practices and payment audit policies that prioritize patients. Instead of being at odds over punitive audit policies, let’s focus on the public health issue sepsis presents to the whole health care community. By coming together in a collaborative manner, we can find a solution that encourages the most effective care for the patients of New Jersey without sacrificing value to all of the stakeholders.