The unexpected consequences of hospital quality scores

By Alice Brewer for HealthcareDive

One clinical affairs expert argues that it’s time to reexamine the federal Hospital-Acquired Condition Reduction Program.

The latest list of hospitals facing federal penalties for poor quality has been released. Through hospital quality scores, the CMS evaluates hospitals on infection rates and other patient complications, reducing their Medicare payment rates accordingly under programs like the Hospital-Acquired Condition Reduction Program (HACRP).

These scores can help patients identify poor-performing hospitals and encourage healthcare organizations to improve their standards of care. Yet, they can also carry unexpected consequences for smaller hospitals with fewer resources, which are often faced with significant financial penalties.

At a time when health equity is in the spotlight, there’s no room for federal programs that endanger under-resourced healthcare facilities and widen disparities for underserved populations. It’s time to examine whether pay-for-performance programs like the HACRP are truly driving quality improvement — or simply creating a burden for rural and safety-net hospitals that can’t afford to be financially penalized.

The high cost of hospital-acquired conditions

In an effort to reduce the growing incidence of hospital-acquired conditions (HACs), the CMS established the HACRP, a quality improvement program which reduces Medicare reimbursements for hospitals with the lowest HAC scores. In 2024 alone, 728 hospitals will face penalties, which can exceed $1 million in some cases.

Contrary to the CMS’ stated goal of improving patient safety and addressing underlying health disparities, these penalties can impact a hospital’s ability to provide quality care and make needed improvements. And though research suggests that repeated HACRP penalties can improve quality scores in U.S. hospitals, this effect may be disproportionate for smaller hospitals and those serving vulnerable populations, which often have fewer resources.

While larger hospitals can absorb large penalties as a simple cost of business, small and mid-size institutions are often forced to cut staff, reduce services and in some cases even shut down for lack of financial viability — reducing access to adequate care in rural and urban medical deserts. This underscores a pressing need for new quality improvement programs that prevent HACs and promote best practices without diverting crucial healthcare resources away from our nation’s most vulnerable populations.

Embracing a layered approach

Ultimately, patient safety is the goal of any healthcare facility. Regardless of a hospital’s size, optimizing quality scores to reduce penalties doesn’t require hospitals to perform a complete overhaul. In fact, the World Health Organization reported that where hand hygiene and other cost-effective practices are followed, up to 70% of infections can be prevented.

Improving HAC scores then may simply be a matter of evaluating existing infection prevention processes, reviewing current best practices and recommended guidelines, and exploring what can be done more effectively.

From a quality perspective, a layered infection approach places multiple layers of defense between a patient and an adverse event, making it the most efficient way to prevent HACs. This means applying multiple disinfection products, interventions, strategies and techniques — from UV technology to surface disinfection to clinical consulting — in a more holistic way to reduce the spread of infection. Often, this may require hospitals to invest in basic improvements upfront to avoid future penalties, saving them vital funds in the long-term.

Moving beyond the numbers

In a time where healthcare transparency is of paramount importance, public reporting of hospital quality scores allows patients to make informed decisions about their care and motivates hospitals to prioritize and drive quality improvement. And while the penalties imposed by the HACRP aim to incentivize better patient safety measures, they also place disproportionate strain on hospitals serving already vulnerable populations.

Looking ahead, it’s imperative for the CMS to prioritize health equity in the design of future quality improvement programs — and for hospitals to mitigate the impact of these penalties by embracing a layered approach to infection prevention, allowing them to continue to provide services to communities in need.