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Deadly infections drive billions in hospital bills to Medicare

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(Bloomberg) — Life-threatening complications from bacterial infections are on the rise among hospital patients, increasing at a double-digit rate as the population ages and costing U.S. health-care programs billions of dollars a year.

One form of the condition, severe sepsis with a major complication, was the second most frequently billed diagnosis submitted by hospitals to Medicare in 2013, with more than 398,000 cases, according to data released Monday from the Centers for Medicare & Medicaid Services.

That’s 15 percent more than in 2012 and 24 percent higher than in 2011, according to a Bloomberg analysis of the Medicare payments. Meanwhile, total payments for major joint replacements, the most commonly billed procedure, rose only 3.3 percent.

The three sepsis-related codes included in Monday’s data accounted for about $7.2 billion of Medicare payments to hospitals, up 9.5 percent from the previous year. Sepsis occurs when the immune system overreacts to a bacterial infection, leading to whole-body inflammation, and can cause blood clots and leaky blood vessels. In severe cases, one or more organs may fail because of the impaired blood flow. As many as half of all people who get sepsis die from it, according to the Centers for Disease Control and Prevention.

“Sepsis is the final path for a lot of patients who are fragile with a lot of medical conditions,” said Adrienne Randolph, a professor at Harvard Medical School and researcher at Boston Children’s Hospital. Those who fall ill can be readmitted to hospitals again and again to combat it, she said.

Hospital data

Among individual hospitals, the largest number of cases billed came from Montefiore Medical Center in the Bronx, New York, with 941 discharges and an average charge of $98,877. Montefiore was followed by Memorial Hermann Hospital System in Houston, with 891 cases, and New York Hospital Medical Center of Queens with 857.

Representatives for the three hospitals didn’t have any immediate comments.

In total, CMS said it released data on $62 billion in Medicare payments to hospitals and outpatient facilities in 2013, representing more than 7 million diagnoses.

Severe sepsis requiring mechanical ventilation was the costliest diagnosis in the Medicare data, which covers the 100 conditions most frequently billed by hospitals. The average charge nationwide was about $170,000, more than a hip or knee replacement or common cardiovascular procedures. Hospitals charged an average of $52,000 for severe sepsis without mechanical ventilation though with major complications.

Medicare typically doesn’t reimburse the full amount charged by a hospital. The total payments by Medicare were calculated using the discharges and average Medicare payment after beneficiary co-payments and deductibles provided in the released data.

Surge in cases

Cases of sepsis almost doubled to 1.7 million in 2009 from 837,000 in 2000, according to the U.S. Health and Human Services Department. The rise was driven by growing numbers of people at risk for the illness, such as the elderly and those with cancer, and increased awareness of how to diagnose and code for the disease, said Eric Adkins, head of the emergency department at Ohio State University’s medical school in Columbus.

“It’s a huge burden from a public health perspective,” Adkins said. “The population of people that are susceptible is growing,” he said. “You’ll see more cases as 50-year-olds become 60-year-olds and 60-year-olds become 70-year-olds.”

Quicker diagnosis

The surge in sepsis cases is changing medical education as well.

“We’re thinking about it upfront more; we’re talking about teaching EMS how to recognize sepsis in the field,” Adkins said, referring to emergency medical services. Though it used to take as much as 18 hours to recognize the disease, emergency workers now “come in the front door saying ‘I think this guy has sepsis.’”

While increased awareness is contributing to more diagnoses, that alone is unlikely to account fully for a 15 percent increase in patients with other major medical issues, which suggests that sepsis cases are in fact increasing, Randolph said Tuesday.

Raymond Thorn, a spokesman for the Centers for Medicare & Medicaid Services, didn’t immediately respond to requests for comment on why sepsis cases are growing.

Payment information

Medicare payments to doctors were long kept from the public after medical associations argued in the early 1980s that their release would violate physicians’ privacy. In May 2013, a federal judge lifted a 33-year-old injunction on the data following a lawsuit by Dow Jones & Co. The Obama administration decided last year to make all payment information public.

The data let the public see not only historical trends in payments but also variations by location and by specific hospitals’ billings.

Every state had an increase in cases related to severe sepsis with major complications, compared with the previous year. Montana and South Dakota were the top gainers, jumping more than 50 percent each, according to Bloomberg analysis of the data.

–With assistance from Zachary Tracer in New York.

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