Penalties didn’t drive drop in hospital-acquired conditions

WHILE THE NUMBER OF PATIENTS with injuries or infections in Michigan declined over an eight-year period, a new study found it wasn’t because of the penalty-driven Hospital-Acquired Condition Reduction Program.

The study, published last week in Health Affairs, found the rate of some hospital-acquired conditions dropped from 61.7 per 1,000 discharges before the program was announced in 2013 to 58.7 after the program was implemented. However, the pace of the decline remained steady prior to and after penalties being in place.

“The trends in hospital-acquired condition reduction didn’t change after the program started,” said Andrew Ryan, an author of the study and director of the Center for Evaluating Health Reform at the University of Michigan. “Patient safety continued to get better but there was no evident inflection point” after the program began.

The results may cast doubt on the impact of the already controversial Hospital-Acquired Condition Reduction Program, which was mandated under the Affordable Care Act to encourage the transition to value-based payment. Hospitals are penalized with a 1% Medicare payment reduction if they perform in the bottom 25% on the conditions compared with their peers. The conditions include pressure injuries, central line-associated blood stream infections, surgical-site infections and catheter-associated urinary tract infections.

Hospitals have complained the program is flawed because it doesn’t recognize improvement. Organizations that perform in the bottom percentile are penalized no matter what.

In an email, a CMS spokesman said the agency “continuously reviews” the penalty program. He added that both the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention have found the program has resulted in declines in hospital-acquired conditions.

Although both of the studies the CMS spokesman referenced from AHRQ and the CDC show a decline in hospital-acquired conditions, they don’t address if it was directly as a result of the penalty program.

The Health Affairs study used data from the Michigan Surgical Quality Collaborative, a statewide patient-safety organization, to get its results. Participation is voluntary and it represents more than 90% of all inpatient surgical procedures in Michigan.

Although the data only concerns hospitals in Michigan, Ryan said the state “is a reasonable test case” of what may be occurring across the country because it’s representative of hospitals nationally and there’s been a statewide focus on injury and infection reduction, making it a “best-case scenario for responding to this program.”

Data from the collaborative was used instead of data the Hospital-Acquired Condition Reduction Program uses, which is from Medicare claims and the CDC, because a previous study from Ryan and others discovered limitations with the datasets to draw conclusions.

Both federal datasets are vulnerable to underreporting because hospitals want to avoid a penalty, Ryan said. The Michigan Surgical Quality Collaborative is used for quality improvement rather than reimbursement, so hospitals are less likely to game it, he added. The measures are manually abstracted from the medical record by clinical staff.

Because the authors used the Michigan Surgical Quality Collaborative, not all measures considered under the Hospital-Acquired Condition Reduction Program are represented in the study, such as pressure injuries and accidental puncture or laceration. But Ryan said many of the measures in the penalty program are surgery-related and most of the claims that have hospital-acquired conditions occur in surgical patients.

It’s difficult to understand why hospitals weren’t influenced by the Hospital-Acquired Condition Reduction Program, Ryan said. It could be that the incentive—a 1% penalty to Medicare payments—wasn’t strong enough.

Considering the results and the concerns with the data the CMS uses to evaluate performance in the program, Ryan said it’s time to reevaluate its future.

“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. ●

The results may cast doubt on the impact of the already controversial Hospital-Acquired Condition Reduction Program, which was mandated under the Affordable Care Act to encourage the transition to value-based payment.