Improving the Hospital-Acquired Condition Reduction Program through Rulemaking.

Hospital-acquired conditions (HACs) are pervasive and expensive, and they cause unnecessary morbidity and mortality. As of 2017, 9 HACs still occurred for every 100 discharges.1 The HospitalAcquired Conditions Reduction Program (HACRP) was created to reduce this rate. Despite the critical need to improve safety, research indicates the HACRP has not been effective. While improvement on claims data–based measures accelerated after HACRP implementation, the program did not improve patient outcomes.2 Risk adjustment is inadequate, leading to disproportionate penalties for teaching hospitals and hospitals caring for more patients with socioeconomic disadvantages.3 Penalization has not improved safety.4 In addition, the HACRP has not been associated with improvement on included measures based on data other than claims5 or high-quality registry data.6 These dismal results highlight 2 HACRP problems: (1) inaccurate, unreliable HAC assessment7 and (2) penalties disproportionately and unfairly affecting certain hospitals. However, crucial modifications could be made through rulemaking. Rulemaking entails the executive branch specifying Congressional policy and regulation details. After public comment and the revision of Federal Register-published proposed rules, a final rule is published creating binding regulations. For Medicare policies, the Department of Health and Human Services (DHHS) plays a leading role. The HACRP legislation (Affordable Care Act section 3008)8 requires that hospitals in the worstperforming quartile by HAC rate receive a 1% Medicare inpatient payment penalty. However, specific measures, performance determination, auditing, and other details are not described. Given this lack of specificity, DHHS has considerable degrees of freedom to improve the HACRP through rulemaking. First, it is necessary to modify measures. A leading strategy to reduce central line bloodstream infections and catheter-associated urinary tract infections is reducing central line or catheter exposure. However, the catheter-associated urinary tract infections measure, for instance, considers only the ratio of infections to catheter days. Since hospitals have experience acquiring catheterization duration data, rewarding decreased catheter exposure would reduce HACs without requiring many documentation changes. Moreover, some outcomes (eg, pneumothorax) are especially preventable and uncommon. It is impossible to reliably distinguish hospitals on these measures. They should be eliminated. Second, the government should improve risk adjustment. Risk adjustment variables are used to calculate hospitals’ expected number of HACs (to compare with the observed number), affecting hospital performance comparisons. Yet the current methodology is insufficient to address the large heterogeneity across patients and hospitals. Compared with other programs, the HACRP measures incorporate wide-ranging diagnoses, increasing heterogeneity in patient characteristics across hospitals. For instance, hospitals performing more surgeries face increased risk for additional HACs, because patients undergoing surgery are eligible for more HACRP measures. Additionally, certain measures omit key patient characteristics that increase risk of HACs. For example, the risk adjustment for surgical site infections neglects (1) preoperative diagnosis, (2) whether the case is elective or emergency, and (3) patient immunosuppression status—despite the association of these variables with risk and their variations across hospitals. Although risk adjustment can never fully address such differences, the current methodology can be improved. One approach is enhancing risk adjustment variables to better account for patient Author affiliations and article information are listed at the end of this article.