HHS: Medicare spent more than $40 billion on sepsis in 2018

February 19, 2020
Medicare Web

Sepsis hospitalizations are on the rise and cost Medicare more than $40 billion in 2018, according to a U.S. Department of Health and Human Services (HHS) study published in the March issue of Critical Care Medicine. Although the cost per inpatient to treat sepsis declined between 2012 and 2018, an increase in the number of patients with sepsis caused Medicare spending on sepsis to almost double in that time.

The study looked at all Medicare claims from 2012-2018 for an inpatient admission that included one or more explicit sepsis codes. During that period, Medicare enrollment increased by 22% while sepsis-related inpatient admissions among beneficiaries rose by 40%. In 2012, the average payment per patient was $21,922 for inpatient care and for Part B services was $2,300 for Part B services. In 2018, the average payment per patient was $19,738 for inpatient care and $2,316 for Part B services. However, in 2012 Medicare’s total payments to treat sepsis were $27.7 billion; in 2018 that jumped to more than $41.5 billion.

The study authors estimated that Medicare may have spent more than $60 billion to treat sepsis in 2019.

An HHS press release notes that Medicare has taken a number of steps to improve the quality of sepsis treatment and control costs. For example, the study found that most patients arrived at the hospital with sepsis as opposed to acquiring it in the hospital, suggesting that CMS’ programs to reduce hospital-acquired cases have yielded some success.

In addition, CMS recently took steps to encourage development and use of innovative antibiotics. In the fiscal year (FY) 2020 Inpatient Prospective Payment System  final rule, CMS finalized changes to improve access to innovative antibiotics under the new technology add-on payment (NTAP) policy for qualified infectious disease products (QIDP). Starting in FY 2020, the NTAP payment for QIDPs was increased to 75% of the cost of the product or the additional cost of the case, whichever is lower.

Sepsis remains one of the most difficult conditions to diagnose and treat and poses unique documentation and coding challenges. Organizations should ensure clinical staff are following the appropriate guidelines for diagnosing and treating sepsis. Review any reporting measures, such as the Inpatient Hospital Quality Reporting Program, that cover sepsis. CDI and coding staff should be kept up-to-date on the applicable coding and documentation guidelines. Organizations may also consider their options for providing QIDPs and reviewing the applicable billing and coding instructions.