Hospital-Acquired Conditions (HAC) Reduction Program

Our last blog provided some background on the READMISSIONS REDUCTION PROGRAM —a three-year rolling process of reporting all-cause readmissions within 30 days of discharge, along with potential penalties.1  Today, we’ll look at the third program established by the Affordable Care Act (ACA): the HOSPITAL-ACQUIRED CONDITIONS (HAC) REDUCTION PROGRAM.

HAC REDUCTION PROGRAM allows the Centers for Medicare & Medicaid Services (CMS) to reduce payments by 1% to hospitals in the worst-performing quartile.2 The CMS reduces payments for specific safety issues and hospital-acquired infections3

  • CAUTI | Catheter Associated Urinary Tract Infection
  • CLABSI | Central Line Associated Bloodstream Infection
  • SSI | Surgical Site Infection
    • Abdominal hysterectomy
    • Colon surgeries
  • MRSA | Methicillin-Resistant Staphylococcus Aureus Bacteremia
  • CDI | Clostridium Difficile Infection

HACs are acquired by patients while receiving care and represent the most frequent adverse event affecting patient safety worldwide.4 For FY 2017, CMS estimated that overall payments to 769 hospitals would drop by roughly $430 MILLION.5

There are two domains associated with the HAC REDUCTION PROGRAM.3:

DOMAIN 1 is based on Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) 90 Composite Component Measures and provides an overview of hospital-level quality as it relates to a set of potentially preventable hospital-related events associated with harmful outcomes for patients.6 It is weighted 15%.4

DOMAIN 2 includes standardized infection ratios (SIRs) calculated by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Healthcare-Associated Infection (HAI) Measures.4 It is weighted 85%.4

Domain 1 is a weighted average of the 
risk- and reliability-adjusted versions of:

  • Pressure Ulcer Rate
  • Iatrogenic Pneumothorax Rate
  • In-Hospital Fall with Hip Fracture Rate
  • Perioperative Hemorrhage or Hematoma Rate
  • Postoperative Acute Kidney Injury Rate
  • Postoperative Respiratory Failure Rate
  • Perioperative Pulmonary Embolism (PE) or
  • Deep Vein Thrombosis (DVT) Rate
  • Postoperative Sepsis Rate
  • Postoperative Wound Dehiscence Rate
  • Unrecognized Abdominopelvic Accidental
    Puncture Laceration Rate

Domain 2 is Center for Disease Control’s (CDC) calculated standardized infection ratios (SIRs) for the CLABSI, CAUTI, and SSI measures. SIRs are ratios of observed-to-predicted numbers of HAIs. The CLABSI, CAUTI, and SSI measures are risk-adjusted at the hospital level and patient-care unit level:

  • CAUTI
  • CLABSI
  • SSI
  • Abdominal hysterectomy
  • Colon surgeries
  • MRSA Bacteremia
  • CDI

If you’ve been following our blog, you’ll probably remember that measures from Domain 2, which make up 85% of the weighting, are penalized in multiple programs—here, in the HAC Reduction Program as well as in the Value-Based Purchasing Program (VBP).

What’s the impact? Consider an average 300-bed Community Hospital with 48% of their patients being Medicare beneficiaries. If they have an inpatient Medicare revenue of $26,000,000 and received a $20,000 payment reduction for a condition/diagnosis, their 1% penalty reduction would be $200. That same reduction would be applied to EVERY inpatient Medicare claim submitted during the fiscal year and could result in a penalty of $260,000.

According to the CMS, there’s good news—improvements are being made. Across the last three fiscal years, 2015, 2016, and 2017, the average performance across eligible hospitals improved for the mean Catheter-Associated Urinary Tract Infection (CAUTI) standardized infection ratio (SIR) and the mean SIR decreased from 1.12 in FY 2015 and 1.17 in FY 2016 to 0.91 in FY 2017.7

If you’d like a comprehensive overview of the Affordable Care Act as featured in our last 4 blogs, click here to download the “True Transparency in the Cost of Care” infographic.

Come back next time when we review some of the latest clinical evidence on CAUTI risk reduction presented at the APIC Annual Conference 2017.

Minimizing infection risk is an essential part of optimizing “The Triple Aim” of the Affordable Care Act. Eloquest Healthcare is committed to providing solutions that can help you reduce risk of conditions like a CAUTI, CLABSI, or SSI.

References

  1. Understanding the Hospital Readmissions Reduction Program. The Lake Superior Quality Innovation Network, Centers for Medicare & Medicaid Services Quality Improvement Organization Program. https://www.stratishealth.org/documents/Readmissions_Reduction_Fact_Sheet.pdf.  Published November 2014. Accessed January 16, 2017.

  2. Hospital-Acquired Condition Reduction Program (HACRP). Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html. Accessed January 16, 2017.

  3. FY 2017 HACRP Key Dates Matrix. Hospital-Acquired Condition Reduction Program (HACRP). Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html. Accessed January 16, 2017.

  4. Health care-associated infections fact sheet. World Health Organization. http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf. Accessed March 30, 2017.

  5. Haefner M. 769 hospitals see medicare payments cut over high HAC rates: 7 things to know. http://www.beckershospitalreview.com/quality/769-hospitals-see-medicare-payments-cut-over-high-hac-rates-7-things-to-know.html. Published December 22, 2016. Accessed January 16, 2017

  6. PSI 90 Fact Sheet. AHRQ Quality Indicators. Agency for Healthcare Research and Quality. https://www.qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf. Published FY 2016. Accessed March 30, 2017.

  7. FY 2017 HACRP Fact Sheet. Hospital-Acquired Condition Reduction Program (HACRP). Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/HAC-reduction-program.html. Accessed March 30, 2017.

Readmissions Reduction Program

Our last post provided an explanation of the VALUE-BASED PURCHASING PROGRAM (VBP), which links financial incentives to a provider’s performance on a defined set of measure domains.1 This time, we’ll take a look at another program established by the Affordable Care Act (ACA): the READMISSIONS REDUCTION PROGRAM.

The READMISSIONS REDUCTION PROGRAM is a three-year rolling process of reporting all-cause readmissions within 30 days of discharge. They are categorized as follows2:

  • AMI | Acute Myocardial Infarction
  • HF | Heart Failure
  • PN | Pneumonia
  • COPD | Chronic Obstructive Pulmonary Disease
  • CABG | Coronary Artery Bypass Grafting
  • THA | (elective) Total Hip Arthroplasty
  • TKA | (elective) Total Knee Arthroplasty

Each hospital receives an “Excess Readmissions Ratio,” which is a measure of a hospital’s readmission performance compared to the national average for the hospital’s set of patients with that applicable condition.2 The calculation uses a risk adjustment methodology endorsed by the National Quality Forum (NQF) for the readmissions measures to calculate the excess readmission ratios. It includes adjustments for factors that are clinically relevant including patient demographic characteristics, comorbidities, and patient frailty.2

The READMISSIONS REDUCTION PROGRAM, is a three-year rolling program that is scheduled as follows:

The table below shows a recap of the first 5 years of the Readmissions Reduction Program.3

Year penalties applied
2013 2014 2015 2016 2017
Percent of hospitals penalized 64% 66% 78% 78% 79%
Percent of hospitals at maximum penalty 8% 0.6% 1.2% 1.1.% 1.8%
CMS estimate of total penalties $290 M $227 M $428 M $420 M $528 M

The increase in average and total penalties for 2017 is due mostly to a larger number of medical conditions added to the calculations for FY 2017 (eg, the types of pneumonia cases that were assessed and calculated readmission rates following CABG surgery).3

For an example of what this might mean, let’s look at an average 300-bed Community Hospital with 48% of their patients being Medicare beneficiaries. If they have an inpatient Medicare revenue of $26,000,000 and received a $20,000 payment reduction for a condition/diagnosis, a maximum 3% penalty would be $600. That same reduction would be applied to EVERY inpatient Medicare claim submitted during the fiscal year and could result in a penalty of $780,000.

And while the READMISSIONS REDUCTION PROGRAM has spawned some key programs, such as Accountable Care Organizations (ACOs), bundled-payment initiatives, and medical home programs3, there is growing scrutiny of the program that suggests it is unfair. According to a new study published in JAMA Cardiology, the program may unfairly level 30-day readmission penalties against hospitals that care for more severely ill patient populations.4

For the study, researchers examined one-year heart attack outcomes for more than 50,000 patients treated at 377 hospitals. Researchers identified no difference in one-year mortality rates and long-term readmission rates between hospitals deemed to have high readmission rates per the 30-day standard.

Ambarish Pandey, MD, a cardiologist with the University of Texas Southwestern Medical Center in Dallas and one of the study’s authors said, “The current CMS readmission metric does not correlate with long-term clinical outcomes.”

We’ll have to wait and see how the Centers for Medicare and Medicaid Services (CMS) responds. Join us for our next blog, when we’ll look at Hospital-Acquired Conditions Reduction Program and its effect on your institution.

Minimizing infection risk is an essential part of optimizing “The Triple Aim” of the Affordable Care Act. Eloquest Healthcare is committed to providing solutions that can help you reduce risk of conditions like a CAUTI, CLABSI, or SSI.

References:

  1. Hospital Value-Based Purchasing. Department of Health and Human Services, Centers for Medicare & Medicaid Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Published April 18, 2016. Accessed January 16, 2017.
  2. Understanding the Hospital Readmissions Reduction Program. The Lake Superior Quality Innovation Network, Centers for Medicare & Medicaid Services Quality Improvement Organization Program. https://www.stratishealth.org/documents/Readmissions_Reduction_Fact_Sheet.pdf. Published November 2014. Accessed January 16, 2017.
  3. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program. The Henry J. Kaiser Family Foundation. http://kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/. Accessed March 30, 2017.
  4. Pandey A, Golwala H, Hall HM, et al. Association of US Centers for Medicare and Medicaid Services Hospital 30-Day Risk-Standardized Readmission Metric With Care Quality and Outcomes After Acute Myocardial Infarction. JAMA Cardiology, 2017. DOI: 10.1001/jamacardio.2017.1143 5. UT Southwestern Medical Center. Readmission policies don’t correlate to heart attack outcomes. Science Daily. https://www.sciencedaily.com/releases/2017/04/170426183038.htm. Published April 26, 2017. Accessed May 25, 2017.

A Breakdown of the ACA and What it Means to Your Hospital

The Affordable Care Act (ACA) created a national quality strategy for the triple aim of better care, healthy people and communities, and affordable care.1 It also initiated a significant transition from fee-for-service to value-based care.

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