HAC penalties shine spotlight on safety while prompting questions about fairness
Hospitals respond to Medicare reimbursement cuts for more than 700 hospitals
It was a moment that the healthcare community had been reluctantly anticipating for some time: Medicare payment cuts to hospitals with high healthcare-acquired condition (HAC) rates offers a stark overview of patient safety deficiencies, while also prompting calls regarding the true fairness of the measure.
In December, the federal government announced it would cut payments to 721 hospitals, from October 1, 2014 through September 2015. The cuts came as a mandate from the Affordable Care Act, which required CMS to identify the lowest quarter of hospitals based on HAC rates, including bed sores, blood clots, central line-associated bloodstream infections (CLABSI) catheter-associated urinary tract infections (CAUTI), along with other preventable complications. The cuts will save approximately $373 million, according to CMS.
The cuts hit academic centers particularly hard. According to an analysis by Kaiser Health News, approximately half of the penalized hospitals are teaching hospitals. Perhaps more surprising was the fact that many hospitals that received HAC penalties were well-known and reputable medical centers, often highly ranked by other quality organizations. In fact, of the 17 hospitals that earned a spot on U.S. News and World Report's 2014?2015 Honor Roll, nine of them were penalized for HAC rates.
For many, the penalties also raise serious concerns regarding the efficacy of these measurements and the fairness of the data that is collected. Some argue that large academic medical centers that serve a high-risk patient population are unfairly targeted.
"When we boil it down, we don't think a quarter of the hospitals should necessarily be penalized when performance does not significantly differ among those hospitals and others that escape a penalty," says Nancy Foster, vice president for quality and patient safety policy for the American Hospital Association in Washington, D.C. "It's really about incentivizing good performance or penalizing bad performance. And one ought to be able to say with confidence that you've identified those whose performance is subpar and warrants penalties."
Although penalties have furthered the discussion regarding comparative quality metrics, few would argue that it has also turned a brighter spotlight on specific patient safety issues.
Are the penalties fair?
If the metrics used to calculate the HAC penalties are too broad and cumbersome to accurately compare hospitals, the question arises: Are the CMS penalties fair?
The problem that many providers have is the fact that the metrics used by CMS make it difficult to compare larger hospitals with smaller hospitals, or inner-city hospitals that serve a complex patient population with community hospitals.
"Essentially CMS is trying to make a horse and buggy do what a Ferrari should be used to do," Foster says. "It's inadequate to the task of really correctly identifying individual hospitals whose performance levels are inferior."
The measurements do not adjust for the multiple factors that contribute to HACs, like documentation, coding, and the underlying complexity of the patient population, says Michelle Schreiber, MD, senior vice president and chief quality officer at Henry Ford Health System in Detroit, Michigan. Two hospitals within the system?Henry Ford Hospital, an 800-bed inner-city facility, and Henry Ford Macomb Hospital, a 400-bed community academic hospital?received penalties for high HAC rates.
"Large complex hospitals are statistically more likely to have some complications," Schreiber says. "For example, catheter-related bloodstream infections are expected to occur in an ICU setting approximately one in 1,500 line days. A small hospital could have 1,500 line days in three years. Henry Ford Hospital has 2,000 line days per month. The metrics do not adjust well for hospital exposure level, nor for how long an IV has been in place, nor for acuity of the patients."
Tony Adire, MD, senior vice president of quality and patient safety at Lehigh Valley Health Network in Allentown, Pennsylvania, echoes similar sentiments. Two hospitals within the network?Lehigh Valley Hospital and Lehigh Valley Hospital Muhlenberg?were among the 721 penalized hospitals.
"Despite our best efforts to fight this or get them to have appropriate quality metrics that make sense, [CMS] kind of does what they want to do and we have to live with it," he says.
The simple answer is no, the metrics are not fair, says Greg Meyer, MD, MSc, chief clinical officer of Partners Health System in Boston, Massachusetts and vice chair of the board of directors with the National Patient Safety Foundation (NPSF). Partners Health System includes Brigham and Women's Hospital, which was penalized, and Massachusetts General Hospital, which was not.
Meyer says the metrics aren't perfect, but they are the best we have at the moment. "When you have tools you want to be able to apply broadly across the country, you're going to rely on measurements that are going to be imperfect," he says. "Are these great metrics? No they aren't. Are they as good as you can get from administrative data? They probably are."
Moreover, tying HACs to reimbursement is bound to grab the attention of healthcare providers.
"I think to some extent, when a financial penalty is imposed, it's absolutely a turnoff to the provider community, but it does also gain a whole lot of attention," Meyer says.
Responding to cuts
The way that hospitals and health systems respond to HAC penalties will determine how patient safety efforts fare over the next several years. Meyer believes there are three ways that health systems will respond. The hope is that these penalties will give hospitals an opportunity to alter underlying processes in healthcare to improve outcomes. However, he says two other responses could occur that could be detrimental to patient care.
First, hospitals could throw "unsustainable resources" at the problem, like hiring additional nurses. The second, more malevolent response is to "game the system," by adjusting coding or reporting practices that will push hospitals out of the bottom quarter.
"Like any other policy intervention, it's always a blunt tool," he says. "You'd like it to be surgical in that it just does good things and doesn't cause those pernicious downstream effects, but the truth of the matter is that it's pretty blunt policy instrument and we can expect all three of those behaviors. And my hope is we'll see much more of the first than the second or the third, but there is no doubt there is a mixture of all three going around the country."
Rather than fretting over the implications of the HAC penalties, Meyer says he hopes hospitals focus more on whether they are making patient safety improvements. He also hopes that punitive approach to HACs doesn't drive the issue "underground," creating an environment in which institutions are hesitant to openly address patient safety issues to avoid financial repercussions.
"What I'm expecting of my organization is that we are open, honest, and learning," he says. "Whether or not we take the penalty, that's secondary to whether care is getting better over the long run, and that's a pretty generalized attitude."
Foster says most hospitals are taking the penalties in stride, but it's not necessarily affecting their approach to patient safety.
"I'm not hearing hospitals say that the publication of this data is driving them to do something radically different," she says. "It's the continuation of their patient safety efforts and the successes that they have experienced extending them even more patients."
For many other institutions, the HAC penalties do not change their approach to quality improvement. Adire says that Lehigh Valley Health Network had a team in place evaluating each of the PSI 90 indicators before the penalties were announced. Lehigh Valley is part of the University Hospital Consortium (UHC), a membership group consisting of 117 academic medical centers and over 328 affiliated hospitals. Collaborative quality and patient safety collaborative projects within that organization have been invaluable to improving patient care.
Additionally, there has been a noticeable attitude shift when it comes to patient safety, Adire says, one that was in motion long before these penalties came into play.
"There was a time when I think the attitude of hospital-acquired conditions was different where people thought, 'Hey, that's just the risk of being in the hospital,'" he says. "We know now through our collaborations over the past two decades with [the Institute for Healthcare Improvement] that we can not only reduce mortality, but reduce harm to patients."
Some have argued that the fallout from the HAC penalties may force hospitals to shift their focus toward billing and coding, which will take away from patient safety efforts. Schreiber says Henry Ford Health System has already started working on collaborative projects with "billers, coders, physicians, and electronic medical records teams" to improve documentation and coding, but not at the expense of patient safety efforts. Rather, these collaborations will be used to highlight opportunities for improvement.
Hospitals that are discouraged by the HAC program won't get much relief in the coming years. CMS plans to include surgical site infections for colon surgeries and abdominal hysterectomies for fiscal year (FY) 2016, and MRSA and C. difficile infections for FY 2017.
Adire says juggling the current penalties with upcoming categories isn't going to change the way his system approaches care. "We apply the same principles to every surgical patient, so it's not going to change what we do, it just adds to the scope of what we can be penalized for," he says.
Ultimately, Meyer points to the principles of just culture, which dictates that individuals should be held accountable for their actions, but punishment is only appropriate if that individual is exhibiting reckless behavior. Instead of punishment, systemic failures should be resolved through coaching and process improvement.
Applying the same situation to HAC penalties, Meyer says hospitals are being punished for errors that aren't driven by reckless behavior.