Hospitals with the highest rates of preventable adverse events will soon see their Medicare reimbursements cut by 1%.
The Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP) is a product of the Affordable Care Act, implemented to tackle the high number of patients who experience avoidable, adverse—and too often fatal—medical events in the hospital; however, while patient safety has been a crucial issue for years, and one largely ignored by Congress until recently, some experts say the new metrics used to evaluate safety and penalize the bottom 25% of hospitals are imprecise and stand to punish those that serve the sickest patients and those that are among the most diligent about tracking patient safety.
“The biggest surprise was how big of a difference there was between academic medical centers and safety-net hospitals and everybody else,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System, professor of health policy at the Harvard School of Public Health, and part of a team that recently used the CMS measures—patient safety indicators (PSI), central line-associated bloodstream infections (CLABSI), and catheter-associated urinary tract infections (CAUTI)—to evaluate where the nation’s hospitals might fall under HACRP.
In its analysis, Dr. Jha’s team found that major teaching hospitals are 2.9% more likely to be penalized under the program than nonteaching hospitals. Large, urban, public, teaching hospitals in the Northeast, with lots of poor patients, have a 62% chance of being penalized, compared to just a 9% chance for small, rural, for-profit, nonteaching hospitals in the South.
In 1998, the Institutes of Medicine estimated that nearly 100,000 patients die every year due to preventable medical errors. A recent estimate in the Journal of Patient Safety says this number may now be as high as 440,000.
In 2012, CMS reported that one in eight Medicare patients incurred a potentially avoidable complication while in the hospital, a 9% reduction from the previous baseline in 2010.
Patient safety clearly is an issue in the United States. But whether all of the HACRP metrics decided upon by CMS are appropriate is up for debate.
“PSI scores…were initially developed to look at healthcare trends broadly and not for comparing institutional performance,” says Ken Sands, MD, MPH, senior vice president of healthcare quality and chief quality officer at Beth Israel Deaconess Medical Center. “They were hijacked for that purpose, and a lot of the measures are based on administrative data.”
Dr. Sands, like Dr. Jha, is concerned that variation in the way hospitals code can influence the rate of adverse events reported through PSIs—which scan billing codes for hospital complications—without a clearly defined set of rules and without clearly defined language. Hospitals vary in how hard they look for complications and in how diligently they code, Dr. Jha says. Hospitals looking for safety issues are more likely to find and code for them, compared to less attentive institutions.
“It’s an inexpensive way to collect data nationally,” Dr. Sands says. “But whether we’re discriminating on quality is not that clear.”
Beth Israel ranks better than most U.S. hospitals on measures of mortality yet falls to the bottom quartile of the hospital-acquired condition (HAC) measures. The medical center may be penalized starting in October.