Maine Medical Center and seven other Maine hospitals have been fined by the federal government because they were in the bottom 25 percent of hospitals in the nation for patients contracting avoidable infections.

Maine Med’s score was the worst in Maine, and the Portland hospital had a much higher infection rate than the national median.

Even so, Dr. Joshua Cutler, vice president of quality and patient safety at Maine Med, said the hospital’s infection rate has declined significantly over the past 10 years because of reforms that have been put in place. But more improvement is needed, Cutler said.

While the exact dollar figure of the fine is an estimate based on a formula, Cutler expects that Maine Med will have to pay the U.S. Centers for Medicare and Medicaid Services, or CMS, more than $1 million.

“Every time there’s an infection now, we assemble a team of physicians and nurses and do a root-cause analysis of why the infection may have happened in the first place,” Cutler said. “The way we look at it is (that) much of these occurrences are avoidable.”

The federal government evaluates infections in a number of categories where hospitals can improve patient safety – such as urinary tract infections from catheters, infections from central line catheters placed in large veins, and infections resulting from common surgeries such as hysterectomies. The scores are one facet of sweeping Affordable Care Act reforms that aim to improve patient safety.

CMS calculates a composite score – using a formula that adjusts the infection rates for factors that include the size and type of hospital and number and type of patients – to rate the hospitals on a scale of 1 to 10, with 10 being the worst.

Maine Med scored a 9.75, the worst in Maine, although it was an improvement over 2014’s 10 score, the first year the federal government rated the hospitals. The median national score among 3,358 hospitals rated was 5.5, and 758 hospitals paid a fine. The actual infection rates aren’t released as part of CMS reports.

The other Maine hospitals that incurred a fine for having higher-than-average infection rates were Mercy Hospital in Portland, Central Maine Medical Center and St. Mary’s Regional Medical Center in Lewiston, MaineGeneral Medical Center in Augusta, Eastern Maine Medical Center in Bangor, York Hospital and Maine Coast Memorial in Ellsworth.

Andrew Coburn, a professor of public health at the University of Southern Maine, said CMS is prodding hospitals to improve patient safety and provide effective treatments for patients by using incentives and penalties. Coburn would like to see more rewards for hospitals that make progress on their weak areas, even if the hospitals score below average. “These are really difficult, complex issues,” he said. “But they get everyone’s attention.”

Coburn said that when a hospital excels, it should be rewarded by CMS.

“There needs to be positive and negative incentives for these programs to work best,” he said.

For instance, Maine Med is rated as one of the top hospitals in the country for preventing avoidable readmissions, but there’s no financial reward for being among the best in that category. However, the penalties for having a poor readmission rate are triple that of infections.

Another problem, critics say, is comparing hospitals that have divergent missions and patient populations.

Although a formula used by CMS does take into account the more severe and complex patients at some hospitals, a research article in the July 2015 edition of the Journal of the American Medical Association said the formula is flawed. The federal agency doesn’t accurately account for hospitals that have much different patient populations, such as an urban hospital, or a major teaching hospital that conducts many procedures, versus a small community hospital that refers patients with more severe conditions to larger hospitals, the article said.

But Cutler said regardless of mitigating circumstances, improving the infection rate is one of the hospital’s top priorities.

“We are over the ‘Our patients are sicker’ excuse. We need to make more improvements,” Cutler said.

Some of the more recent reforms, Cutler said, have dramatically reduced infections for patients using catheters, but those dropoffs occurred in 2015 and won’t be calculated by CMS until next year. Although the latest numbers were released Dec. 10 by CMS, they are based on data from 2013-14.

Also, the rate of infections after surgeries has decreased from 2.5 infections per 100 operations in 2006 to 1.6 in 2015, according to internal documents provided by Maine Med. But the infection rate after common surgeries was still above average when compared with most hospitals, according to the CMS data.

Cutler said another beneficial reform is that Maine Med professionals no longer draw blood from central line catheters. It’s convenient to do so, but it has proved to be a risk factor for infection, Cutler said.

The teams that examine why an infection might occur inevitably notice how they could have done more to prevent infections, and that is helping to get a handle on them.

“Sometimes there’s a cynical attitude, ‘Of course they were at risk for infection, because they were a leukemia patient,’ ” said Cutler, referring to a common example. Leukemia patients are immune-compromised and at greater risk for infections.

But what the teams have found, he said, “is that when they actually look at the procedures in place, they find out that they could have done more to prevent an infection.”

Although Maine Med’s fine will be steep, it’s counteracted by a financial reward that MaineHealth received for a different program that rewards health systems for improving patient outcomes.

In 2014, MaineHealth, the parent company of Maine Med, received a $9.2 million rebate from the federal government for saving the Medicare system money with effective care programs, including the low readmission rate and giving patients preventive screenings.