CMS Program May Overly Penalize Top-Tier Hospitals

Tara Haelle

July 29, 2015

Major teaching hospitals and those hospitals with more quality accreditations, more advanced services, and better outcomes measures were penalized more than other hospitals in the Hospital-Acquired Condition (HAC) Reduction Program, according to a study published in the July 28 issue of in JAMA.

"[T]raditional quality metrics (eg, accreditations, process measures, mortality) may be flawed and thus conflict with hospital HAC measure performance," suggest Ravi Rajaram, MD, from the Northwestern University Feinberg School of Medicine, Chicago, Illinois, and colleagues, in discussing how to interpret their findings. "Alternatively, the HAC Reduction Program may not accurately measure hospital quality."

The fiscal year 2015 HAC program, run by the Centers for Medicare & Medicaid Services, reduces payments to hospitals with the poorest performance based on the HAC criteria. In the current study, the researchers compared hospital characteristics and penalization in the HAC program based on data from the FY2015 HAC program, the 2014 American Hospital Association Annual Survey, and the Fiscal Year 2014 Medicare Impact File.

An overall 22.0% of the 3284 participating hospitals were penalized, with larger hospitals making up a larger share of those penalties than smaller hospitals. More than a third (38.7%) of hospitals with at least 400 beds were penalized compared with 13.9% of hospitals with fewer than 100 beds. Similarly, 35.4% of hospitals with the highest quartile of admissions were penalized compared with 13.5% of hospitals in the lowest quartile.

Compared with the 17.0% of nonteaching hospitals that were penalized, 42.3% of major teaching hospitals (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.09 - 2.29) and 62.2% of very major teaching hospitals (OR, 2.61; 95% CI, 1.55 - 4.39) were penalized. In addition, nearly a quarter (24.0%) of those hospitals with Joint Commission accreditation were penalized compared with 14.4% of those without (OR, 1.33; 95% CI, 1.04 - 1.70).

Those with the most complex patient population (highest quartile using a case mix index) had double the odds of penalization compared with those with the least complex populations (lowest quartile), with 32.8% of the former hospitals and 12.1% of the latter receiving penalties (OR, 1.98; 95% CI, 1.44 - 2.71). Nearly half of the level I trauma centers (47.4%) compared with the non-level I trauma centers (19.1%) were penalized, and 28.3% of safety net hospitals and 19.9% of non-safety-net hospitals were penalized (OR, 1.36; 95% CI, 1.11 - 1.68).

The researchers assigned each hospital an 8-point hospital quality summary score based on the institution's volume, accreditations, and availability of advanced care services. Then they compared these summary scores with both the HAC program penalization and process-of-care and outcome measures in surgery, acute myocardial infarction, heart failure, and pneumonia at each hospital.

Hospitals with higher-quality summary scores showed better performance than hospitals with lower scores on all 10 publicly reported process and outcomes measures except one: discontinuing antibiotics within 24 hours after a surgery. Those institutions with the highest score, however, were penalized at more than five times the rate of those with the lowest score. Specifically, 67.3% of the 55 hospitals with a score of 8 were penalized (95% CI, 54.9% - 79.7%) compared with 12.6% (95% CI, 9.4% - 15.7%) of the 422 hospitals with a quality score of 0 (P < .001).

"These findings suggest that penalization in the HAC program may not reflect poor quality of care, but rather, these findings may be due to measurement and validity issues of the HAC program component measures," the authors write.

"One explanation for these findings may be that these component measures are affected by surveillance bias, where differences in clinical practice result in varying rates of identifying an adverse outcome," they note.

"[H]ospitals that are more thorough in identifying events may be more susceptible to penalties in the HAC program."

The authors also suggested that differences among hospitals in information technology might account for better identifying adverse events and that that inadequate adjustment for risk based on patient population differences may also lead to greater penalization among hospitals with higher quality measures.

The research was supported by the Agency for Healthcare Research and Quality, the American College of Surgeons Clinical Scholars in Residence Program, and Merck. One coauthor has received support from the American Board of Surgery, American College of Surgeons, Accreditation Council for Graduate Medical Education, National Comprehensive Cancer Network, American Cancer Society, Health Care Services Corporation, California Health Care Foundation, the Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Foundation, and Northwestern Memorial Hospital and honoraria from hospitals and professional societies for clinical care and quality improvement research presentations. The other authors have disclosed no relevant financial relationships.

JAMA. 2015;314:375-383. Abstract


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