As the federal government penalizes 751 hospitals for having too many infections and patient injuries, some states are feeling the cuts in Medicare payments more than others.
This year's punishments landed the toughest in Connecticut and Delaware, where Medicare penalized half of the evaluated hospitals, federal records show. In New York and Nevada, 4 in 10 hospitals were penalized. A third were punished in Rhode Island and Georgia. (These figures do not include specialty hospitals automatically exempted from penalties: those serving veterans, children and psychiatric patients, and “critical access” hospitals that are the only real institutions within their area.)
While every state except Maryland – which is excluded since it has a different Medicare payment system – had at least one hospital punished, some departed comparatively lightly. Sixteen percent of hospitals or fewer in Alabama, Kansas, Massachusetts, Missouri, Ohio, Texas and nine other states were punished. (State summaries are below; a searchable list of individual hospitals penalized is here now.)
The penalties – now within their fourth year – were created through the Affordable Care Act they are driving hospitals to improve the caliber of their care. Every year, countless hospitals lose 1 % of the Medicare payments through the Hospital-Acquired Conditions (HAC) Reduction Program.
The program's design is stern: Out of the roughly 3,300 general hospitals that are evaluated each year, Medicare must punish the worst-performing quarter of these – even when they have reduced their quantity of potentially avoidable mishaps from the previous evaluation period.
“I have seen with my own eyes the improvement,” said Dr. Amy Boutwell, a quality-improvement consultant in Massachusetts. “I hear hospitals say straight up, 'We don't wish to maintain the cheapest quartile, you want to get out of the penalty zone.'”
The conditions Medicare considers include rates of infections from colon surgeries, hysterectomies, urinary system catheters and central line tubes inserted into veins. Medicare also examines rates of methicillin-resistant Staphylococcus aureus, or MRSA, and Clostridium difficile, referred to as C-diff. The frequency of 10 kinds of in-hospital injuries, including bedsores, hip fractures, blood clots, sepsis and post-surgical wound ruptures, are also assessed. Each one of these kinds of potentially avoidable events are classified as hospital-acquired conditions, or HACs.
A mix of factors contribute to why more hospitals are punished in a few states. The penalties fall more often on teaching hospitals and hospitals with large servings of low-income patients. There are other of these in certain states compared to others. Some penalty recipients say Medicare isn't adequately considering variations in patients, since those who are frailer tend to be more prone to HACs.
There is also some element of statistical chance, because the number of reported conditions in one hospital on the fringe of the bottom quartile might just have one or two more incidents than the usual hospital that narrowly escapes that designation.
Some repeatedly penalized hospitals, for example Northwestern Memorial Hospital in Chicago, the program is flawed by what researchers call surveillance bias: The hospitals which are most diligent in testing and treating infections and injuries are likely to have the symptoms of more than comparatively lackadaisical institutions. The hospitals are responsible for reporting incidents to the federal government.
Medicare says it performs spot-checks, but Dr. Karl Bilimoria, director from the Surgical Outcomes and Quality Improvement Center in the Northwestern University Feinberg Med school, said more policing is required for that rates to be credible.
“In no other industry would this pass, in which a program without an audit and voluntary data reporting could be considered valid,” Bilimoria said. “We know guys are gaming.”
Still, many hospitals which have large numbers of sicker and low-income patients, or that handle more complex cases, have avoided the penalties. Medicare issued no punishments this year to Cedars-Sinai Medical Center in La; the Cleveland Clinic; Intermountain Clinic in Murray, Utah; Massachusetts General Hospital in Boston; or New York-Presbyterian Hospital in Manhattan. While safety-net and teaching hospitals were penalized at a higher rate than other hospitals, two-thirds of every group escaped penalties this season.
Dr. Kevin Kavanagh, board chairman of Health Watch USA, a patient advocacy group, asserted most hospitals are reducing their HACs every year, partly due to the penalties.
“That's really the bottom line that everyone should support,” he said. “No product is perfect.”