The number of sepsis cases is on the rise, and the Centers for Medicare and Medicaid Services (CMS) continues to promote a sense of urgency for hospitals to address sepsis. This deadly condition claims some 270,000 lives annually.The Centers for Medicare & Medicaid Services (CMS) recently approved including SEP-1 quality measure in its Hospital Value-based Purchasing (HVBP) Program. With this change to VBP, there will be financial implications for your hospital's sepsis performance. SEP-1 will be added to the VBP program's safety domain in the fiscal 2026 program year, which begins in October 2025.
Another way CMS focuses on sepsis is by publicly reporting sepsis hospital performance on its public portal, Hospital Compare, which was introduced in July 2018. Soon after, Hospital Compare reported that the national average percentage of patients who received appropriate care based on CMS sepsis core measures for severe sepsis and septic shock was 49 percent.
The effort to make hospitals’ sepsis care public follows the introduction of CMS’s hospital reporting on Core Measure SEP-1: Early Management Bundle, Severe Sepsis/Septic Shock—in its Inpatient Quality Reporting program, which began in October 2015. Since then, the measure has undergone modifications, requiring hospitals to make corresponding changes to how they document and report their adherence to the measure. At least for now, failure to complete any aspect of the bundle in the given time period earns hospitals a zero score for those patients.
SEP-1 compliance improves patient outcomes
Peer-reviewed studies have concluded that compliance with the sepsis protocol produces better patient and financial outcomes.
Studies show that patients who receive care according to the steps and timing described in the bundle have:
- 17% shorter median length of stay when care was compliant
- 6% reduction in 30-day mortality
- 5% decrease in readmissions for patients who receive SEP-1 bundle
Challenges with sepsis management, no second-guessing
As most hospitals know all too well, there is a range of issues involved in sepsis management – from the complexity of diagnosis to siloed data and documentation issues. Then, there is the CMS sepsis bundle itself. SEP-1 compliance requires the completion of multiple components within a short window of time and involves a multidisciplinary team beyond front-line clinicians.
Due to the complexity of differential diagnosis, sepsis often goes underreported and underdiagnosed. There is no single test for the condition; a diagnosis requires experienced clinical judgment based on complex clinical factors. Speed in diagnosis and treatment is essential to avoid lengthy hospital stays and increased morbidity and mortality, yet over-reporting can pose a problem. Today, many hospitals rely on systems vendors build into Electronic Health Record systems (EHRs) to scan for abnormal systemic inflammatory-response-syndrome (SIRS) criteria, which can serve as an early warning system for sepsis. Such systems tend to be sensitive—they capture many potential sepsis cases—but are also highly imprecise, generating false positives and corresponding alert fatigue among clinicians who tend to tune out alerts that constantly fire off. Because these systems often falsely identify patients as being septic, they may be incorrectly counted in the denominator of the SEP-1 measure.
Even if a hospital team has the right tools, the appropriate change management, and strong internal protocols, the sepsis measure can still be challenging. Successful sepsis reporting requires abstracting the measure quickly to deliver feedback to leadership about daily performance; it also involves improving that performance. Once a health system or hospital has found a way of effectively adopting evidence-based practices, they must hard-wire those processes into care delivery so the results are sustainable.
Unfortunately, the answer to how to improve performance is not a simple one.
Taking a lesson from those hospitals that have seen some of the best outcomes, organizations must consider a multidisciplinary approach backed by sophisticated clinical surveillance solutions that draw on vast clinical content, proven practices, and change management specifically aimed at compliance with the CMS sepsis bundles. There also needs to be transparency so clinicians can see what interventions were the most effective and track progress on outcomes and how their actions impact compliance and performance.
The financial upside to effective sepsis management
Beyond the obvious, a positive impact on patient health is a financial implication for more effective sepsis management. According to the Agency for Healthcare Research and Quality (AHRQ), sepsis is consistently the most expensive hospital stay, costing the U.S. healthcare system approximately $38 million annually, and those costs have been rising by about 8% a year as our population ages and hospitalized patients are more clinically complex. A recent analysis found the total hospital costs per sepsis case were, on average, $18,500 to $57,000 in developed countries and the U.S. However, the typical Medicare reimbursement for sepsis and sepsis with complications is significantly lower.
Sepsis is clearly in the financial crosshairs—and with good reason. It’s second on the list in clinical variability, which is one of the five most worrisome issues for CEOs identified by The Advisory Board, along with identifying innovative approaches to expense reduction and controlling unavoidable utilization.
Sepsis volume has more than doubled, and inpatient mortality rates have grown by 20% in the past decade. And, at 48%, it is the inpatient service with the highest growth projection from 2020 to 2025.
The future of sepsis management: what's next with VBP and SEP-1?
Now that CMS is including SEP-1 in its VBP Program, the stakes are higher than ever. VBP Program participation is mandatory, and quality results can affect hospital payments. Hospitals that perform well receive a bonus funded by the hospitals that do poorly. Results are publicly reported via Medicare.gov. Hospitals must have access to tools that help identify patients early and accurately, that deliver rapid treatment that is in full compliance with CMS bundles, and that carefully monitor how clinicians respond within their workflow to deliver the necessary clinical support to save both lives and money.
Public Reporting via Hospital Compare
As part of the public reporting, CMS posts a rolling-years’ worth of data on Medicare’s public portal Hospital Compare. The data reflects SEP-1 scores and is updated quarterly in January, April, July, and October each year. At the start of each new quarter, another quarter’s worth of information is released, and the oldest quarter will be removed. According to CMS, SEP-1 is grouped with other clinical process-of-care measures under the Timely and Effective Care tab. Other measures appearing under that tab include flu immunization, emergency department time to admit and volume, blood clot acquired in the hospital, and perinatal care.
Individual hospital performance is displayed as a percentage derived from the numerator/denominator calculation reported. For example, a hospital that reports 78 of 100 patients were properly treated in accordance with the sepsis measure bundle would be 78%. For a hospital reporting fewer than 11 cases total, no data is reported.
On the Hospital Compare display page, an individual hospital’s performance is also compared with (1) the performance of the top 10% of hospitals reporting on SEP-1, (2) the average performance of the hospitals reporting in that hospital’s state, and (3) the national average which is 58% currently.
Managing sepsis continues to be a top priority for organizations across the country. With the stakes higher than ever with SEP-1 compliance addition to the VBP program, hospitals need tools to support their care teams in early and accurate sepsis alerts, support in the delivery of care that is SEP-1 compliance, and the ability to support sepsis performance improvement.
