SUMMARY

• The U.S. Center for Medicare and Medicaid Services (CMS) Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) lays out the process for providers to follow in the care of the sepsis patient.
• First published in 2015, then amended in 2018, CMS is recommending SEP-1 become added to the Hospital Value Based Purchasing Program (HVBP) starting FY2026.
• Coupled with a multiplier for care of the underserved patient population, the SEP-1 measure can net a 2.8% increase as part of the inpatient prospective payment system.
• However. specific conditions must be met.

BACKGROUND

• The CMS SEP-1 sepsis measures became quality indicator metrics in 2015
• The goal of SEP-1 was to promote quality and cost effective care on a national level.
• 2018 unveiled the newest version of the sepsis guidelines and was very similar to the 2015 guidelines.
  • Hospital sepsis compliance data became publicly available.

• The FY 2024 CMS Hospital Inpatient prospective payment system (PPS) made a number of rule changes.
• The only new measure was the addition of the Severe Sepsis an d Septic Shock Management Bundle.

REVIEW

• The global burden of sepsis is not in debate.
• The continued variability of care of sepsis still remains
• The value of compliance with the CMS SEP-1 sepsis bundles has yet to be resolved.
  • Rhee et al JAMA Netw Open. 2021;4(12):e2138596. doi:10.1001
  • No change in mortality after SEP-1 initiation

• Townsend SR et al CHEST 2022; 161(2):392-406
  • Compliance with SEP-1 decreased 30 day mortality

• Potential reasons for varying results with SEP-1 compliance
  • Changing guidelines and definitions
  • 4 Surviving Sepsis campaign guidelines
  • 3 International Consensus definitions
• SEP-1 uses outdated definitions (Sepsis-2 definitions from 2001, published in 2003).

APRIL 2023

• CMS issued fiscal year 2024 hospital inpatient prospective payment system (IPPS) rules
• An overall 2.8% increase for inpatient IPPS payments will occur
  • Hospitals not submitting quality data will only get 2.05% increase
  • Hospitals not meeting EHR meaningful use will only get 0.55% increase.
  • Hospitals not meeting both will get a payment decrease of 0.2%
• Significant changes to Hospital Value Based Purchasing Program (HVBP)
  • Beginning in FY2026 CMS will add a Health Equity Adjustment (HEA)
  • HEA will be a total performance score consisting of 2 parts:
    • High quality performance
    • Extent to which underserved patients are served = proportion of dual eligible patients for Medicare and Medicaid
• Points will be assigned based on whether the hospital scores in the:
  • Top Third
  • Middle Third
  • Bottom Third
• THE ONLY NEW MEASURE ADDED TO HVBP IS SEVERE SEPSIS AND SEPTIC SHOCK MANAGEMENT BUNDLES

CONCLUSIONS

• CMS Sepsis SEP-1 management bundle elements have evolved from:
  • 2015 Quality Performance Items
  • 2018 Publicly Available Quality Data
  • FY2026 Tied to hospital reimbursement
• Although the net 2.8% increase is felt by many to be inadequate, the amount maybe lower if inpatient prospective payment programs are sub-optimal
• Health systems must be ready for this sepsis reimbursement change.

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Erkan Hassan is the Co-Founder & Chief Clinical Officer of Sepsis Program Optimization where he designs & oversees the implementation of solutions to optimize sepsis programs.

To discuss your organization’s Barriers of Effective Sepsis Care, contact Erkan by phone (844) 4SEPSIS (844-473-7747), email (erkan@spo.icu), or video chat.