HACs may not tell the whole story

The Affordable Care Act has essentially overhauled Medicare’s payment system for hospitals in an effort to improve quality while minimizing wasteful spending.

One such change centers on HACs, or hospital-acquired conditions. These conditions were deemed potentially preventable by the Centers for Medicare & Medicaid Services in 2009 and are a major target for Medicare payment penalties and hospital quality initiatives. Hospitalizations that are complicated by one of these conditions, for instance, the development of diabetic ketoacidosis from poor glycemic control, do not qualify for higher paying diagnosis-related group payment, leaving a gaping hole between the cost of care delivered and the amount reimbursed by Medicare.

Yet to come in fiscal year 2015, Medicare payments for all discharges will be cut by 1% for those hospitals that score in the top quartile for the rate of hospital-acquired conditions, compared with national average.

Upon initially hearing about this provision in the ACA, I was shocked and felt it was both unfair and realistic, but as time has passed, it is clear that a variety of innovative hospital-based quality initiatives have made significant headway into minimizing at least some of the HACs.

Help is also available through the government. The Medicare Shared Savings and Pioneer ACO Models offer participating hospitals a share of the savings if they can reduce spending below historical benchmarks. A healthier bottom line for our hospitals has the potential to ultimately translate into improved resources and support systems to enhance our ability to provide excellent care for our patients, while making our days run more smoothly.

However, a recent study shows that HACs do not appear to be the bottom line in hospital savings after all. Identifying hospital-wide harm associated with increased cost, length of stay, and mortality in U.S. hospitals, was recently released by the Premier health care alliance, and was based on peer-reviewed research in the American Journal of Medical Quality.

Premier evaluated more than 5.5 million deidentified ICD-9 discharge records from hospitals and medical centers in 47 states. They identified 86 potential inpatient complications that were associated with higher cost, increased length of stay, and/or higher mortality.

Surprisingly, this study concluded that the current HACs used by the CMS cover only a fraction of the complications and that of the 86 high-impact conditions they evaluated, only 22 are addressed through the CMS’s federal payment policies. Conditions such as acute renal failure, which was associated with close to $490 million in costs, and hypotension, which had $200 million in costs in this study were far more significant than were the HACs such as air embolism and blood incompatibility, seen in 23 and 8 patients, respectively, in more than 5 million records.

While some of the 86 conditions identified may not be easy to prevent, others, such as acute renal failure and hypotension, have the potential to be significantly reduced through vigilant monitoring of parameters such as nephrotoxin use and blood pressure trends.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

The Affordable Care Act has essentially overhauled Medicare’s payment system for hospitals in an effort to improve quality while minimizing wasteful spending.

One such change centers on HACs, or hospital-acquired conditions. These conditions were deemed potentially preventable by the Centers for Medicare & Medicaid Services in 2009 and are a major target for Medicare payment penalties and hospital quality initiatives. Hospitalizations that are complicated by one of these conditions, for instance, the development of diabetic ketoacidosis from poor glycemic control, do not qualify for higher paying diagnosis-related group payment, leaving a gaping hole between the cost of care delivered and the amount reimbursed by Medicare.

Yet to come in fiscal year 2015, Medicare payments for all discharges will be cut by 1% for those hospitals that score in the top quartile for the rate of hospital-acquired conditions, compared with national average.

Upon initially hearing about this provision in the ACA, I was shocked and felt it was both unfair and realistic, but as time has passed, it is clear that a variety of innovative hospital-based quality initiatives have made significant headway into minimizing at least some of the HACs.

Help is also available through the government. The Medicare Shared Savings and Pioneer ACO Models offer participating hospitals a share of the savings if they can reduce spending below historical benchmarks. A healthier bottom line for our hospitals has the potential to ultimately translate into improved resources and support systems to enhance our ability to provide excellent care for our patients, while making our days run more smoothly.

However, a recent study shows that HACs do not appear to be the bottom line in hospital savings after all. Identifying hospital-wide harm associated with increased cost, length of stay, and mortality in U.S. hospitals, was recently released by the Premier health care alliance, and was based on peer-reviewed research in the American Journal of Medical Quality.

Premier evaluated more than 5.5 million deidentified ICD-9 discharge records from hospitals and medical centers in 47 states. They identified 86 potential inpatient complications that were associated with higher cost, increased length of stay, and/or higher mortality.

Surprisingly, this study concluded that the current HACs used by the CMS cover only a fraction of the complications and that of the 86 high-impact conditions they evaluated, only 22 are addressed through the CMS’s federal payment policies. Conditions such as acute renal failure, which was associated with close to $490 million in costs, and hypotension, which had $200 million in costs in this study were far more significant than were the HACs such as air embolism and blood incompatibility, seen in 23 and 8 patients, respectively, in more than 5 million records.

While some of the 86 conditions identified may not be easy to prevent, others, such as acute renal failure and hypotension, have the potential to be significantly reduced through vigilant monitoring of parameters such as nephrotoxin use and blood pressure trends.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

The Affordable Care Act has essentially overhauled Medicare’s payment system for hospitals in an effort to improve quality while minimizing wasteful spending.

One such change centers on HACs, or hospital-acquired conditions. These conditions were deemed potentially preventable by the Centers for Medicare & Medicaid Services in 2009 and are a major target for Medicare payment penalties and hospital quality initiatives. Hospitalizations that are complicated by one of these conditions, for instance, the development of diabetic ketoacidosis from poor glycemic control, do not qualify for higher paying diagnosis-related group payment, leaving a gaping hole between the cost of care delivered and the amount reimbursed by Medicare.

Yet to come in fiscal year 2015, Medicare payments for all discharges will be cut by 1% for those hospitals that score in the top quartile for the rate of hospital-acquired conditions, compared with national average.

Upon initially hearing about this provision in the ACA, I was shocked and felt it was both unfair and realistic, but as time has passed, it is clear that a variety of innovative hospital-based quality initiatives have made significant headway into minimizing at least some of the HACs.

Help is also available through the government. The Medicare Shared Savings and Pioneer ACO Models offer participating hospitals a share of the savings if they can reduce spending below historical benchmarks. A healthier bottom line for our hospitals has the potential to ultimately translate into improved resources and support systems to enhance our ability to provide excellent care for our patients, while making our days run more smoothly.

However, a recent study shows that HACs do not appear to be the bottom line in hospital savings after all. Identifying hospital-wide harm associated with increased cost, length of stay, and mortality in U.S. hospitals, was recently released by the Premier health care alliance, and was based on peer-reviewed research in the American Journal of Medical Quality.

Premier evaluated more than 5.5 million deidentified ICD-9 discharge records from hospitals and medical centers in 47 states. They identified 86 potential inpatient complications that were associated with higher cost, increased length of stay, and/or higher mortality.

Surprisingly, this study concluded that the current HACs used by the CMS cover only a fraction of the complications and that of the 86 high-impact conditions they evaluated, only 22 are addressed through the CMS’s federal payment policies. Conditions such as acute renal failure, which was associated with close to $490 million in costs, and hypotension, which had $200 million in costs in this study were far more significant than were the HACs such as air embolism and blood incompatibility, seen in 23 and 8 patients, respectively, in more than 5 million records.

While some of the 86 conditions identified may not be easy to prevent, others, such as acute renal failure and hypotension, have the potential to be significantly reduced through vigilant monitoring of parameters such as nephrotoxin use and blood pressure trends.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.