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Original Investigation
March 2015

Effect of Medicare’s Nonpayment for Hospital-Acquired Conditions: Lessons for Future Policy

Author Affiliations
  • 1Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
  • 2Department of Statistics and Data Sciences, The University of Texas at Austin
  • 3Department of Integrative Biology, The University of Texas at Austin
  • 4Department of Health Administration, Virginia Commonwealth University, Richmond
  • 5Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
  • 6Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
  • 7School of Nursing, University of Kansas Medical Center, Kansas City, Missouri
  • 8Department of Biostatistics, School of Medicine, University of Kansas Medical Center, Kansas City, Missouri
  • 9Department of Health Policy and Administration, Pennsylvania State University, University Park
  • 10Department of Statistics, University of Florida, Gainesville
  • 11Department of Epidemiology, University of Florida, Gainesville
  • 12Geriatric Research Education & Clinical Center, Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida
JAMA Intern Med. 2015;175(3):347-354. doi:10.1001/jamainternmed.2014.5486
Abstract

Importance  In 2008, Medicare implemented the Hospital-Acquired Conditions (HACs) Initiative, a policy denying incremental payment for 8 complications of hospital care, also known as never events. The regulation’s effect on these events has not been well studied.

Objective  To measure the association between Medicare’s nonpayment policy and 4 outcomes addressed by the HACs Initiative: central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure ulcers (HAPUs), and injurious inpatient falls.

Design, Setting, and Participants  Quasi-experimental study of adult nursing units from 1381 US hospitals participating in the National Database of Nursing Quality Indicators (NDNQI), a program of the American Nurses Association. The NDNQI data were combined with American Hospital Association, Medicare Cost Report, and local market data to examine adjusted outcomes. Multilevel models were used to evaluate the effect of Medicare’s nonpayment policy on never events.

Exposures  United States hospitals providing treatment for Medicare patients were subject to the new payment policy beginning in October 2008.

Main Outcomes and Measures  Changes in unit-level rates of HAPUs, injurious falls, CLABSIs, and CAUTIs after initiation of the policy.

Results  Medicare’s nonpayment policy was associated with an 11% reduction in the rate of change in CLABSIs (incidence rate ratio [IRR], 0.89; 95% CI, 0.83-0.95) and a 10% reduction in the rate of change in CAUTIs (IRR, 0.90; 95% CI, 0.85-0.95), but was not associated with a significant change in injurious falls (IRR, 0.99; 95% CI, 0.99-1.00) or HAPUs (odds ratio, 0.98; 95% CI, 0.96-1.01). Consideration of unit-, hospital-, and market-level factors did not significantly alter our findings.

Conclusions and Relevance  The HACs Initiative was associated with improvements in CLABSI and CAUTI trends, conditions for which there is strong evidence that better hospital processes yield better outcomes. However, the HACs Initiative was not associated with improvements in HAPU or injurious fall trends, conditions for which there is less evidence that changing hospital processes leads to significantly better outcomes.

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