A new study published in JAMA suggests that hospitals being penalized under CMS's Hospital-Acquired Condition (HAC) Reduction Program "may not reflect poor quality of care" and that there might be broader issues with the program.
Background on HAC penalty program
For the HAC Reduction Program, CMS assesses rates of 10 patient injuries at hospitals, including blood stream infections, patient falls, bed sores, urinary tract infections, collapsed lungs, cuts that occur during or after surgery, and blood clots.
CMS calculates each facility's HAC score on a scale from one to 10, with 10 being the greatest rate of patient harm. The worst-performing quartile of hospitals are penalized 1% of their inpatient Medicare revenue.
The agency penalized 721 hospitals—or about 22% of the nearly 3,300 participating—in the program's first year.
Hospital-acquired conditions: The pay-for-performance game changer?
Details of the study
For the study, researchers looked at fiscal year (FY) 2015 HAC data as well as results from the 2014 American Hospital Association Annual Survey and the FY2014 Medicare Impact File.
The study found that certain hospital types were more likely to be penalized than others.
- Admissions: About 35.5% of hospitals in the highest quartile of admissions were penalized compared with 13.5% of hospitals in the lowest quartile;
- Beds: About 39% of facilities with at least 400 beds were penalized compared with about 14% of facilities with fewer than 100 beds;
- Joint Commission accreditation: 24% of Joint Commission-accredited hospitals were penalized compared with about 14.5% of non-accredited hospitals;
- Patient mix: About 33% of hospitals with the most complex patient populations were penalized compared with about 12% of hospitals with the least complex patient populations;
- Safety net status: About 28% of safety net hospitals were penalized compared with about 20% of non-safety net hospitals;
- Teaching hospitals status: About 62% of very major teaching hospitals and 42% of major teaching hospitals were penalized, compared with 17% of non-teaching hospitals;
- Trauma center status: About 47.5% of level I trauma centers were penalized, compared with about 19% of non-level I trauma centers.
The researchers also created a hospital quality summary score, where facilities received a point for each of eight characteristics, including Joint Commission accreditation, level I trauma center status, provision of transplant services, and other measures. Overall, they found the hospitals that received the highest score of eight were penalized more than five times as frequently as those with the lowest score.
Are the measures working?
The authors wrote that the findings could indicate that traditional quality metrics—such as accreditations, process measures, and mortality rates—are flawed.
But the findings, they wrote also "suggest that penalization in the HAC program may not reflect poor quality of care," such as that hospitals which are "more thorough" in terms of identifying adverse events could be more likely to face penalties.
Karl Bilimoria, director of the Surgical Outcomes and Quality Improvement Center at Northwestern University and a co-author of the study, was less diplomatic in an interview with MedPage Today's "The Gupta Guide." He said the findings demonstrate that CMS was "not penalizing the right hospitals."
Bilimoria added that the program could cause hospitals to seek to focus on the wrong quality metrics (Haelle, Medscape, 7/29; Rice, Modern Healthcare, 7/28; Firth, "Gupta Guide," MedPage Today, 7/28).
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