Federal programs that evaluate hospital quality, like the Hospital-Acquired Condition Reduction Program (HACRP), were designed to improve patient safety by penalizing hospitals with high rates of hospital-acquired conditions (HACs). While these programs can drive quality improvements and help patients make informed choices, they often have significant, unintended effects, particularly on under-resourced hospitals serving rural and underserved communities. Alice Brewer, Senior Director of Clinical Affairs at PDI Healthcare, argues that it's time to rethink the structure of the HACRP and other pay-for-performance programs to better balance quality goals with the realities faced by healthcare facilities of all sizes.
The Financial Burden on Under-Resourced Hospitals
The HACRP reduces Medicare reimbursement rates for hospitals with high rates of HACs, such as infections, surgical complications, and injuries acquired during hospital stays. In 2024, 728 hospitals will face financial penalties under this program, with some hospitals incurring losses that can exceed $1 million. While larger healthcare systems may absorb these penalties as part of their operational budget, smaller hospitals—especially those in rural areas or urban neighborhoods with limited healthcare options—struggle to cope with these financial setbacks.
These penalties can force under-resourced hospitals to make difficult decisions, including staff reductions and scaling back services. In some cases, repeated penalties contribute to a hospital’s closure, which reduces access to care in areas that already lack adequate healthcare facilities. This trend counters the intent of the HACRP by weakening healthcare providers that serve vulnerable communities, which leads to greater health disparities and diminishes healthcare equity.
Striking a Balance with a Layered Approach
To meet the goals of the HACRP without crippling hospitals financially, experts recommend a more layered approach to infection prevention and quality improvement. Hospitals do not need an extensive overhaul to improve their quality scores; rather, they can make significant strides through proven, cost-effective practices. Studies from the World Health Organization have shown that up to 70% of infections can be prevented through basic measures like hand hygiene, which hospitals of any size can implement.
The layered approach involves multiple, complementary strategies to prevent HACs, such as using advanced disinfection products, leveraging UV light technologies, and training staff in stringent hygiene protocols. By incorporating several defenses against infection, hospitals can achieve better patient outcomes and avoid penalties, all without excessive costs. Small, targeted improvements upfront can reduce long-term costs by avoiding penalties and preserving funds to serve patient needs.
Beyond the Numbers: A Push for Health Equity
The transparency offered by public hospital quality scores empowers patients to choose safer healthcare facilities, which in turn motivates hospitals to adopt better practices. However, it’s essential that these programs consider the financial and operational limitations of hospitals that serve disadvantaged populations. While the HACRP’s penalties aim to incentivize improved safety, they can have a counterproductive effect by adding burdens to already struggling hospitals.
Moving forward, the Centers for Medicare & Medicaid Services (CMS) should prioritize equity when designing future quality improvement programs. Programs like the HACRP should be restructured to reward hospitals for incremental improvements, support resources for under-resourced facilities, and avoid broad penalties that disproportionately impact hospitals based on their size or location.
Ultimately, effective quality improvement programs should strive for safety and equity in equal measure. By embracing a layered infection-prevention approach and rethinking the structure of the HACRP, healthcare providers and policymakers can work together to improve patient care standards while protecting the resources needed to serve vulnerable populations.
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