Hospital-Acquired Conditions & The Hospitalist

IS HAC PROGRAM First Round of Payment Changes?

Hospital-acquired conditions (HACs) most likely are just the first round of carrots and sticks to be introduced into the U.S. healthcare payment system. It has long been a desire of Congress to have Medicare become a value-based purchaser in all realms of medical services.

“One of the biggest criticisms over the last few years of Medicare’s payment system is that we pay for quantity but not quality,” Dr. Straube says. “Historically, anything that happened, good or bad, we paid for. Now we are saying ‘the times, they are changing,’ and we are, too, by paying more for higher-quality and less for lower-quality care.”

Although HAC is the main component of the early iterations of CMS’ value-based purchasing, few expect it will remain the only component. Right now, CMS is withholding HAC payment from hospitals. The next logical step will be to include physicians and other providers in the mix.

“The Senate Finance Committee wants to extend value purchasing to all providers,” Dr. Berenson says. “One could enunciate a principle that providers should be rewarded for better performance.”

The biggest question is whether the current measures are up to that kind of challenge. In fact, some controversy already is building around HAC nonpayments, which most healthcare experts view as the low-hanging fruit of value-based purchasing in healthcare.

“One of the points of most discussion is how preventable some of these are, particularly when choosing those you are no longer going to pay for,” Dr. Meddings says. “Many of the complications currently under review have patients that are at higher risk than others.

“How much our prevention strategies can alleviate or reduce the risk varies widely among patients.”

She points to DVT as an example. For a certain number of patients, the guidelines can be followed perfectly, yet some factors specific to that individual result in a DVT occurring. Under the HAC rules, there is no method to account for this, and the only way to appeal a nonpayment decision is to contest or change the coding.

“Can we come up with good-enough measures to make this more than a token approach to quality at all levels?” Dr. Berenson asks. “Otherwise, we are putting a significant amount of revenues at risk, and some of us are not sure that is the best way we can get to higher quality.”—KU