Influence of Billing Models in the Decision of Hospital Administrators to Implement Effective Infection Control Programs

Background: Nosocomial infections (NI) increase healthcare costs due to the extra in-patient-days, the increased use of specific resources and the opportunity cost arising from the lack of availability of beds to admit new patients. Although an effective hospital infection control program (HICP) can release these beds, there are inherent costs associated with each intervention making necessary to evaluate the net benefits that its application produces. The economic value of a bed occupied by a patient without NI regarding a patient with NI varies depending on the provider billing model (BM) (case-module, per diem-module, and fee-for-service payment) and may influence the decision of hospital administrators to implement certain HICPs. It is important that infection control managers understand this type of analysis to promote the most efficient HICPs.

Objective: To apply an economic model to understand the influence of different BMs on the decision of hospital administrators to implement HICPs.

Methods: An economic model developed by Graves (Emerg Infect Dis 2004, 10: 561-66) was applied to in-patient data obtained from a social security healthcare system from Argentina. Hospital costs were reported in US dollar (adjusted to 2007 year present value), and estimated from the financier's billings, by applying a ratio of 0.60 (cost/tariffs). Based on this information, fixed and variable costs, per-case and per-day were calculated. Using a global NI rate of 7.4 %, an average of 6.42 extra-inpatient days and an additional variable cost of $1,011 per event, total inpatient cost and the average length of stay for patient with and without NI were calculated. This information was then applied for estimating the marginal cost under the scenario of different provider BMs.

Results: Only those BMs with some level of risk transfer between financer and provider (case-module and per diem-module) show an economic advantage from the hospital administrator perspective to apply certain HICPs because the opportunity cost is negative (average profit in infected patients-average profit in non-infected patients). Since the marginal cost varies between both BMs, there are differences between them at the maximum threshold of acceptable cost-effectiveness for the implementation of HICPs. On the other hand, in the fee-for-service model, hospitals fully transfer its risk to financiers so that their income is not compromised by the occurrence of these events, not existing in this case, economic incentives to apply any HICPs.

Conclusions: Given that in our country the most common BM between financer and provider is fee-for-service, there are no economic incentives to implement HICPs. In this context, the state and funders should require that the social perspective is considered over the provider interest, demanding the universal application of quality healthcare and patient safety programs.