Paying for Performance: How is the Hospital Acquired Conditions Reduction Program Affecting Safety-Net Hospitals and their Infection Rates? Open Access

Bonisese, Victoria (Spring 2018)

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The Centers for Medicare and Medicaid Services’ (CMS) Hospital Acquired Conditions Reduction Program (HACRP) is a pay-for-performance program that ranks and penalizes hospitals based upon their hospital acquired condition rates. Research on pay-for-performance programs has indicated that safety-net hospitals are disproportionately fined compared to their non-safety-net counterparts. This has led to concern that pay-for-performance policies widen the gap between safety-net and non-safety-net hospitals. Though research has been done on other pay-for-performance programs, it is unclear how HACRP penalties are distributed amongst hospital type and how the policy is affecting the clinical outcome of interest, infection rates.

The purpose of this study is twofold. It examines how penalization by the HACRP is distributed across safety-net and non-safety-net hospitals and how catheter-associated urinary tract infection (CAUTI) and catheter-associated bloodstream infection (CLABSI) rates change after policy implementation.

HACRP performance data (2015-2017) and hospital infection rates (2013-2016) were gathered from Hospital Compare. Hospital characteristics were gathered from the CMS Inpatient Prospective System. Logistic regression was used to examine odds of penalization by the HACRP, and ordinary least squares regression was used to assess CAUTI and CLABSI rates before and after policy implementation.

Safety-net hospitals are 1.32 times more likely to be fined by the HACRP than non-safety-net hospitals. Relative to 2013, the gap in CAUTI rates between safety-net and non-safety-net hospitals closed by 20.2 infections per 1,000 device days. The decline in CLABSI rates was not significant, however this was likely due to a high degree of variation in rates in 2013-2014. Both safety-net and non-safety-net hospitals experienced a 48% reduction in CAUTI rates from 2013-2016, while safety-net hospitals improved their CLABSI rates by 36% and non-safety-net hospitals improved by 19.7%.

This analysis indicates that safety-net hospitals are disproportionately fined under the HACRP. Results also indicate that, despite this penalization difference, safety-net hospitals are improving their infection rates. Although safety-net hospitals are improving, it is important to note that hospitals with lower baseline performance may never improve enough to escape penalization. With this in mind, pay-for-performance policy may benefit from incentives or reduced penalization for lower performing hospitals that reach a specified improvement benchmark.


Table of Contents


I. Introduction 1


II. Background            2


a.         Safety-Net Hospitals   2


a.         CAUTIs, CLABSIs, and Their Implications  5


b.         Pay-for-Performance Programs          6


c.         HACRP Design and Eligible Hospitals          7


d.         Current Literature       8


III. Conceptual Model 10


a.         Safety-net Status as a Moderator        10


b.         Hypotheses     11


IV. Methods    12


a.         Analytic Strategy        12


b.         Measured Confounders          13


c.         Unmeasured Confounders      14


d.         Strengths and Limitations       15


e.         Dataset Description     16


f.          Measures         17


g.         Inclusion & Exclusion Criteria           19


V. Results           20


VI. Discussion    22


VII. Appendix     27


VIII. References  41


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