Changes in Hospital-acquired Conditions and Mortality Associated With the Hospital-acquired Condition Reduction Program

Abstract

Importance: To improve patient safety, the Centers for Medicare and Medicaid Services announced the Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The program reduces Medicare payments by 1% for hospitals in the lowest performance quartile related to hospital-acquired conditions. Performance measures are focused on perioperative care. Objective: To evaluate changes in HACs and 30-day mortality after the announcement of the HACRP. Design: Interrupted time-series design using Medicare Provider and Analysis Review (MEDPAR) claims data. We estimated models with linear splines to test for changes in HACs and 30-day mortality before the Affordable Care Act (ACA), after the ACA, and after the HACRP. Setting: Fee-for-service Medicare 2009–2015. Participants: Medicare beneficiaries undergoing surgery and discharged from an acute care hospital between January 2009 and August 2015 (N = 8,857,877). Main Outcome and Measure: Changes in HACs and 30-day mortality after the announcement of the HACRP. Results: Patients experienced HACs at a rate of 13.39 per 1000 discharges [95% confidence interval (CI), 13.10 to 13.68] in the pre-ACA period. This declined after the ACA was passed and declined further after the HACRP announcement [adjusted difference in annual slope, −1.34 (95% CI, −1.64 to −1.04)]. Adjusted 30-day mortality was 3.69 (95% CI, 3.64 to 3.74) in the pre-ACA period among patients receiving surgery. Thirty-day mortality continued to decline after the ACA [adjusted annual slope −0.04 (95% CI, −0.05 to −0.02)] but was flat after the HACRP [adjusted annual slope −0.01 (95% CI, −0.04 to 0.02)]. Conclusions and Relevance: Although hospital-acquired conditions targeted under the HACRP declined at a greater rate after the program was announced, 30-day mortality was unchanged.

A Comparison of Estimated Cost Savings from Potential Reductions in Hospital-Acquired Conditions to Levied Penalties Under the CMS Hospital-Acquired Condition Reduction Program

“…Total savings to Medicare were calculated by adding the savings associated with hypotheti-cal HAC reductions to the savings from financial penalties ( Figure 1 ). We also estimated savings to Medicare by applying estimates of reductions of specific PSIs, using methods outlined by Arnston et al, 13 to HAC rates during the baseline period.…”

Hospital-Acquired Condition Rate of Admitting Facility Does Not Predict Mortality in Traumatically Injured Patients

“…Despite this reduction, there is evidence that payment penalties have not improved clinical outcomes. Arntson et al showed the rate of 30-day mortality did not decline after the implementation of the HACRP [ 7 ]. Sankaran et al compared hospitals penalized under HACRP versus those not penalized.…”

Association of Stratification by Proportion of Patients Dually Enrolled in Medicare and Medicaid With Financial Penalties in the Hospital-Acquired Condition Reduction Program

“…Safety-net hospitals would still have strong incentive to reduce adverse events but would be more fairly judged against other facilities with a more similar case mix. Further, prior work 5,20,28,29 has found that the HACRP has not yet achieved its goal: the receipt of a penalty has not been associated with a change in the rate of hospitalacquired conditions or in patient outcomes. The HACRP as currently constructed could therefore inadvertently serve an in- After stratification, states that each received a total of less than $1 million in penalties compared with the prestratification scheme included California, Massachusetts, Michigan, and New York; states that each received a total of $1 million or more in penalties included Arkansas, Florida, Kansas, Kentucky, Mississippi, Ohio, Texas, and Virginia.…”

“…Safety-net hospitals would still have strong incentive to reduce adverse events but would be more fairly judged against other facilities with a more similar case mix. Further, prior work has found that the HACRP has not yet achieved its goal: the receipt of a penalty has not been associated with a change in the rate of hospital-acquired conditions or in patient outcomes. The HACRP as currently constructed could therefore inadvertently serve an institutionalized function of penalizing the safety net while also failing to adequately support and catalyze improvement in patient outcomes.…”