Background on the program
The HAC program, which launched in October 2014, evaluates hospitals based on their rates of several avoidable complications, including bed sores, blood clots, central line infections, falls, and infection from methicillin-resistant Staphylococcus aureus (MRSA) or Clostridium difficile (C. diff).
Every year, the facilities in the worst-performing 25% are penalized by losing 1% of their Medicare payments. Since the program was established in 2014, the program has penalized 1,756 hospitals, and 110 of those hospitals have been penalized all five years. Congress exempts the United States' more than 1,000 critical access hospitals, as well as Maryland hospitals and certain specialized hospitals (children's, psychiatric, and veterans), from the penalties.
The hospital industry has argued that the HAC methodology uses an arbitrary cutoff. The American Hospital Association last year published an analysis that found only 41% of the 768 hospitals penalized in 2017 had HAC rates significantly higher than the hospitals that were not penalized. The industry also has argued the methodology punishes hospitals that thoroughly test for infections and other patient-safety hazards, as they might uncover more problems and appear statistically worse than hospitals with lower testing standards.
HACs are down, CDC finds
According to CDC's report, rates of C. diff dropped by 12% between 2017 and 2018, while rates of central line-associated bloodstream infections dropped by 9% and catheter-associated urinary tract infections dropped by 8% during the same time period.
CDC also found that, compared with 2015, every state but one performed better on at least two types of HACs, while 44 states improved on at least three types of HACs and 33 states improved on at least four types.
But is the HAC Program driving the downward trend?
However, according to the Health Affairs study, the decrease in HACs is not driven by CMS' HAC program. For the study, researchers looked at data from the Michigan Surgical Quality Collaborative, a statewide patient-safety organization that represents over 90% of all inpatient surgical procedures in the state.
The researchers used data from the collaborative instead of data from CMS' HAC program because the CMS data comes from Medicare claims and CDC, which—according to Andrew Ryan, director of the Center for Evaluating Health Reform at the University of Michigan and author of the Health Affairs study—contains dataset limitations.
The researchers found that the rate of some HACs in Michigan dropped from 61.7 per 1,000 discharges before the HAC program was announced in 2013 to 58.7 after the program was announced. However, the researchers discovered that the rates declined at a steady pace before and after the program was announced.
"The trends in [HAC] reduction didn't change after the program started," Ryan said. He explained, "Patient safety continued to get better but there was no evident inflection point" once the program started.
While the study deals only with data from Michigan, Ryan said the state "is a reasonable test case" of nationwide trends because there has been a statewide focus on reducing injuries and HACs, meaning the state is a "best case scenario for responding to this program."
Since the data comes from Michigan's collaborative, not all measures under the HAC program are represented, including pressure injuries and accidental punctures or lacerations, Modern Healthcare reports. However, Ryan said many of the measures used in the program are related to surgery, and most HAC claims happen among surgical patients.
In an email to Modern Healthcare, a spokesperson for CMS wrote that the agency "continuously reviews" its HAC penalty program, and added that the Agency for Healthcare Research and Quality, as well as CDC, have found the HAC program has caused declines in HACs.
According to Modern Healthcare, both studies the CMS spokesperson referenced show a decline in HACs, but do not determine whether those declines were directly caused by the HAC program.
Ryan said it is hard to know why the HAC program is not having a larger effect on hospitals, but he said it could be that the 1% penalty to Medicare providers is not strong enough.
Ryan added that it might be time for CMS to re-evaluate the future of the program.
"Perhaps this is just not the right use of resources and effort to be focusing on penalizing on measures that we just think aren't good," he said (Masson, Becker's Clinical Leadership & Infection Control, 11/4; Castellucci, Modern Healthcare, 11/4).