The health care industry continues to transition toward a value-based, pay-for-performance system, but there’s still confusion surrounding the different quality and value programs that have been introduced by CMS and how they impact hospitals.

There’s good reason for the confusion. The programs themselves share terminology, leaving you asking yourself, “How does the HAC Deficit Reduction Act differ from the HAC Reduction Program?”  Further, quality measures, such as catheter-associated urinary tract infection (CAUTI), span all three programs, yet are calculated differently depending on the program.

It’s critically important for stakeholders to understand the components of each program, as well as how the programs are measured, to implement appropriate action plans to improve quality and prevent CMS penalties. We travel the country clearing up the confusion for hospital organizations, and we’re breaking it down for you here.

HAC Deficit Reduction Act

This program includes the traditional hospital-acquired conditions (HAC). All of these conditions qualify as either a complication/comorbidity (CC) or a major complication/comorbidity (MCC). However, if the condition develops after admission, it will be excluded from counting as a CC or MCC for reimbursement purposes. In addition, the first four conditions on the list are publicly reported on the Hospital Compare website.

  • Foreign object retained after surgery **
  • Air embolism **
  • Blood incompatibility **
  • Falls and trauma **
    • Fractures
    • Dislocations
    • Intracranial injuries
    • Crushing injuries
    • Burn
    • Other injuries
  • Stage III and IV pressure ulcers
  • Manifestations of poor glycemic control
    • Diabetic ketoacidosis
    • Nonketotic hyperosmolar coma
    • Hypoglycemic coma
    • Secondary diabetes with ketoacidosis
    • Secondary diabetes with hyperosmolarity
  • CAUTI
  • Vascular catheter-associated infection
  • Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG)
  • Surgical site infection following bariatric surgery for obesity
    • Laparoscopic gastric bypass
    • Gastroenterostomy
    • Laparoscopic gastric restrictive surgery
  • Surgical site infection following certain orthopedic procedures
    • Spine
    • Neck
    • Shoulder
    • Elbow
  • Surgical site infection following cardiac implantable electronic device (CIED)
  • Deep vein thrombosis (DVG) / Pulmonary embolism (PE) Following certain orthopedic procedures
    • Total knee replacement
    • Hip replacement
  • Iatrogenic pneumothorax with venous catherization

**Publicly reported on Hospital Compare

HAC Reduction Program

It’s a startling fact: Under the HAC Reduction Program, hospitals performing in the bottom 25% receive a 1% penalty. The penalty is applied across all Medicare hospitalizations for the year. For a large hospital, the penalty can be over $1 million per year.

The HAC Reduction Program is comprised of patient safety indicator (PSI) 90 (The Patient Safety and Adverse Events Composite), as well as healthcare-associated infections (HAI). PSI 90 was developed by the Agency for Healthcare Research and Quality (AHRQ) and is used to track potential complications and adverse events. Each PSI has unique criteria based on the coded diagnoses in the medical record. Accurate clinical documentation is critical to ensure appropriate clinical care is not inadvertently captured as a complication. PSI 90 is a composite of the following 10 PSIs:

  1. PSI 03 Pressure Ulcers
  2. PSI 06 Iatrogenic Pneumothorax
  3. PSI 08 In Hospital Fall with Hip Fracture
  4. PSI 09 Perioperative Hemorrhage or Hematoma
  5. PSI 10 Post-op Acute Kidney Injury Requiring Dialysis
  6. PSI 11 Post-op Respiratory Failure
  7. PSI 12 Peri-op Pulmonary Embolism or Deep Vein Thrombosis
  8. PSI 13 Postoperative Sepsis
  9. PSI 14 Postoperative Wound Dehiscence
  10. PSI 15 Unrecognized Abdominopelvic Accidental Puncture/Laceration

In contrast to PSIs, HAIs are less dependent on clinical documentation and are instead based on abstraction rules developed by the CDC. The following HAIs are abstracted from the hospital chart and reported to the National Healthcare Safety Network (NHSN):

  • Central line-associated bloodstream infection (CLABSI)
  • Catheter-associated urinary tract infection (CAUTI)
  • Surgical site infection (SSI) (colon and hysterectomy)
  • Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
  • Clostridium difficile infection

Hospital Value-Based Purchasing Program

Performance measures under this program give hospitals the potential for up to a 2% penalty or even a bonus, based on the performance of the various measures. There are four domains that are equally weighted: clinical care, person and community engagement, safety, and efficiency and cost reduction.

Safety Domain

The same five HAIs reported in the HAC Reduction Program are also included in the Hospital Value-Based Purchasing Program.

  • CLABSI
  • CAUTI
  • SSI (colon and hysterectomy)
  • MRSA bacteremia
  • Clostridium difficile infection

In addition, PC-01, elective delivery prior to 39 completed weeks gestation, is included for hospitals that offer obstetrics.

Person and community engagement

This domain is assessed based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).Also known as the CAHPS Hospital Survey, it measures patients’ perceptions of their hospital experiences.

Efficiency and cost reduction

This domain is based on Medicare spending per beneficiary. It is risk adjusted and the spending per beneficiary is compared to all hospitals across the nation. The goal of this measure is to reward hospitals that provide comparable care at a lower cost.

Clinical care

The clinical care domain includes six mortality metrics that are publicly reported:

  • Acute myocardial infarction (AMI)
  • Heart failure (HF)
  • Pneumonia
  • Chronic obstructive pulmonary disease (COPD)
  • Stroke
  • CABG

While all six of these mortality metrics are publicly reported, only AMI, HF, and pneumonia are included in the financial calculation of the Hospital Value-Based Purchasing Program.

Capture POA when clinically appropriate

Medicare’s mortality metric has significant financial and reputation implications. It is important to understand that conditions that develop after admission are not included in the risk adjustment, whereas conditions that are present on admission (POA) are included in risk adjustment.  Herein lies the importance of capturing diagnoses as POA when clinically appropriate.

If it’s unclear whether the condition is POA, a query may be warranted to ensure that all diagnoses that contribute to risk adjustment are captured. Additionally, diagnoses that are coded as W—the provider cannot determine if the condition is POA—are counted as POA and thus used in risk adjustment calculations. It’s also important to note that any conditions that are coded in the 12 months prior to admission are included in risk adjustment. This includes prior hospitalizations as well as outpatient encounters.

How to optimize mortality metrics

We share these recommendations with our own clients on how to optimize mortality metrics:

  • Ensure diagnoses are captured as POA when appropriate
  • Ensure diagnoses capture the appropriate acuity—acute vs. chronic
  • Ensure diagnoses are captured to the highest specificity possible

To avoid penalties and thrive under CMS’s HAC Deficit Reduction Act, HAC Reduction Program and Hospital Value-Based Purchasing Program, it’s critical to have a strong CDI department that works collaboratively with the quality department. In addition, thorough clinical documentation combined with accurate coding is essential to ensure correct CC/MCC assignment and appropriate risk adjustment. And lastly, now that you have this summary as a guide, don’t let all the acronyms confuse you!

Leave a Reply