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Measurement matters: changing penalty calculations under the hospital acquired condition reduction program (HACRP)
Olga A Vsevolozhskaya1, Karina C Manz2, Pierre M Zephyr2
1Department of Biostatistics, University of Kentucky, Lexington, USA.
Insights
Hospital Acquired Conditions Reduction Program penalties shift frequently due to scoring updates. This instability questions the program's effectiveness in improving patient safety and reducing hospital-acquired conditions.
Area of Science:
- Healthcare quality improvement
- Health policy analysis
- Hospital administration
Background:
- The Centers for Medicare and Medicaid Services' Hospital Acquired Conditions Reduction Program (HACRP) penalizes hospitals with high rates of hospital-acquired conditions.
- While initial evaluations suggested HACRP reduced conditions, recent studies show no clear link between penalties and quality of care.
- Frequent scoring methodology updates may explain the disconnect between penalties and actual hospital quality.
Purpose of the Study:
- To evaluate the association between changes in HACRP scoring methodology and shifts in hospital penalty status.
- To assess the sensitivity of HACRP penalties to updates in the program's scoring methodology.
Main Methods:
- Utilized hospital discharge records from 14 states.
- Calculated total HAC scores using FY2015-FY2018 CMS scoring methodologies on FY2018 hospital performance data.
- Compared hospital penalty status across different scoring methodologies over time.
Main Results:
- Significant overlap in penalized hospitals between FY2015/2016 (95%) and FY2017/2018 (46%), but substantial differences across early vs. later years.
- Only 15% of hospitals were penalized across all four years.
- Hospitals experienced significant shifts in relative rankings, indicating penalty status changes were not due to minor score fluctuations.
Conclusions:
- HACRP penalties demonstrate high sensitivity to program updates, often announced after performance periods.
- The timing of these updates creates a disconnect between hospital performance and penalty assignment.
- This instability raises concerns about the HACRP's effectiveness in achieving its intended goal of improving patient safety.
Background:
Since October 2014, the Centers for Medicare and Medicaid Services has penalized 25% of U.S. hospitals with the highest rates of hospital-acquired conditions under the Hospital Acquired Conditions Reduction Program (HACRP). While early evaluations of the HACRP program reported cumulative reductions in hospital-acquired conditions, more recent studies have not found a clear association between receipt of the HACRP penalty and hospital quality of care. We posit that some of this disconnect may be driven by frequent scoring updates. The sensitivity of the HACRP penalties to updates in the program's scoring methodology has not been independently evaluated.
Methods:
We used hospital discharge records from 14 states to evaluate the association between changes in HACRP scoring methodology and corresponding shifts in penalty status. To isolate the impact of changes in scoring methods over time, we used FY2018 hospital performance data to calculate total HAC scores using FY2015 through FY2018 CMS scoring methodologies.
Results:
Comparing hospital penalty status based on various HACRP scoring methodologies over time, we found a significant overlap between penalized hospitals when using FY 2015 and 2016 scoring methodologies (95%) and between FY 2017 and 2018 methodologies (46%), but substantial differences across early vs later years. Only 15% of hospitals were eligible for penalties across all four years. We also found significant changes in a hospital's (relative) ranking across the various years, indicating that shifts in penalty status were not driven by small changes in HAC scores clustered around the penalty threshold.
Conclusions:
HACRP penalties have been highly sensitive to program updates, which are generally announced after performance periods are concluded. This disconnect between performance and penalties calls into question the ability of the HACRP to improve patient safety as intended.
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