Improving the Hospital-Acquired Condition Reduction Program Through Rulemaking

Abstract

Hospital-acquired conditions (HACs) are pervasive and expensive, and they cause unnecessary morbidity and mortality. As of 2017, 9 HACs still occurred for every 100 discharges. 1 The Hospital-Acquired Conditions Reduction Program (HACRP) was created to reduce this rate.Despite the critical need to improve safety, research indicates the HACRP has not been effective. While improvement on claims data-based measures accelerated after HACRP implementation, the program did not improve patient outcomes. 2 Risk adjustment is inadequate, leading to disproportionate penalties for teaching hospitals and hospitals caring for more patients with socioeconomic disadvantages. 3 Penalization has not improved safety. 4 In addition, the HACRP has not been associated with improvement on included measures based on data other than claims 5 or high-quality registry data. 6These dismal results highlight 2 HACRP problems: (1) inaccurate, unreliable HAC assessment 7 and (2) penalties disproportionately and unfairly affecting certain hospitals. However, crucial modifications could be made through rulemaking. Rulemaking entails the executive branch specifying Congressional policy and regulation details. After public comment and the revision of Federal Register-published proposed rules, a final rule is published creating binding regulations. For Medicare policies, the Department of Health and Human Services (DHHS) plays a leading role.The HACRP legislation (Affordable Care Act section 3008) 8 requires that hospitals in the worstperforming quartile by HAC rate receive a 1% Medicare inpatient payment penalty. However, specific measures, performance determination, auditing, and other details are not described. Given this lack of specificity, DHHS has considerable degrees of freedom to improve the HACRP through rulemaking.

Benchmarking hospital safety and identifying determinants of hospital-acquired complication: the case of Queensland cardiac linkage longitudinal cohort

“…Overall, the high cost and high mortality risk associated with HAC suggest that reducing HAC could improve health outcomes and save costs. However, current strategies to reduce HAC focused only on patient characteristics [ 7 ] or incident reporting scores [ 37 ], which has been criticised for not comparing the performance of hospitals with similar characteristics [ 38 , 39 ]. The benchmarking analysis in this study addresses this issue by comparing the safety performance of hospitals with similar characteristics using the data envelopment analysis framework.…”

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.…”

“…[12][13][14] Given similar disparities in other CMS value-based payfor-performance programs, including the Hospital Readmissions Reduction Program (HRRP), 6,[15][16][17] many stakeholders have argued for the inclusion of social risk adjustment when evaluating hospital performance. 5,[18][19][20] In response, the US Congress passed the 21st Century Cures Act in 2016. This act mandates that hospitals in the HRRP be stratified into, and evaluated within, quintiles based on their "proportion dual," which is the proportion of their patients dually enrolled in Medicare and Medicaid.…”

CMS Quality Measure Development—Reply

“…It is challenging to quantify the effect of the CMS hospital value-based programs because they have no control group, were initiated approximately concurrently, and depend on suboptimal measures and coding patterns to detect quality. For example, evaluations of the Hospital Acquired Condition Reduction Program have shown that the program was not associated with improved mortality rates and that its associations with improvements in patient safety are seen in claims-based measures but not in more reliable registry-based measures . Similarly, although early evidence suggested that enactment of the Hospital Readmissions Reduction Program (HRRP) was associated with reductions in readmissions, the observations were primarily driven by coding changes and statistical artifact .…”

“…Perhaps most importantly, these value-based programs are regressive and have disproportionately penalized safety-net hospitals that serve poor and sick populations . Although CMS has saved billions of dollars through the imposition of penalties, the long-term effects of taking resources away from already resource-constrained hospitals may prove to have been penny-wise and pound-foolish.…”