Penalties for hospital-acquired conditions didn't lead to improvements in safety

A study found that large, teaching, and safety-net hospitals were more likely to be penalized by Medicare for their rates of hospital-acquired conditions, suggesting that the penalty program could be decreasing equity without improving quality, according to the study authors.

Hospitals that incurred Medicare penalties for hospital-acquired conditions (HACs) did not show significant improvements in their subsequent HAC rates, a recent study found.

The retrospective cohort study used regression discontinuity design to look at more than 15 million discharges of Medicare fee-for-service beneficiaries from 3,238 acute care hospitals between July 23, 2014, and Nov. 30, 2016, that were eligible for at least one HAC targeted by the penalties. It included 708 of the 724 hospitals penalized for HACs during fiscal year 2015. Results were published by The BMJ on July 3.

The penalized hospitals had 2.72 HACs per 1,000 episodes compared to 2.06 per 1,000 episodes in nonpenalized hospitals. Penalized hospitals were more likely to be large, to be teaching institutions, and to have a greater share of patients with low socioeconomic status. Rates of 30- day readmissions were 14.4% in penalized hospitals and 14.0% in nonpenalized ones, and 30-day mortality was 9.0% in both categories. Penalties were associated with nonsignificant changes in HACs (−0.16 per 1,000 episodes; 95% CI, −0.53 to 0.20), 30-day readmissions (−0.36 percentage point; 95% CI, −1.06 to 0.33), and 30-day mortality (−0.04 percentage point; 95% CI, −0.59 to 0.52).

Previous research had already shown that the HAC penalties particularly affect major teaching hospitals and facilities caring for disadvantaged patients, according to the study authors. “Our findings add to this literature by demonstrating that penalization does not appear to drive performance improvement in the program,” they said. Together these results suggest that the HAC penalty program could be decreasing equity while not improving quality, the authors noted.

They offered a number of potential solutions to this problem, including changing the HAC penalties to be graduated instead of all or nothing for the hospitals in the bottom quarter for performance and modifying penalties based on hospitals' share of disadvantaged patients. The authors also called for additional research to determine whether future measurement and penalty programs are succeeding in improving patient safety.