Medicare and its Hospital Acquired Condition (HAC) Policy

In the United States, the Centers for Medicare & Medicaid Services (CMS) covers many healthcare expenses for Medicare beneficiaries. Beginning in 2008, CMS identified specific "never event" medical complications and conditions for which it penalized medical facilities.

These conditions were called "never events" because they involved scenarios that should never happen to anyone hospitalized for care, such as surgery on the wrong body part.

This article explains the never events policy, known as the Hospital-Acquired Condition (HAC) Reduction Program since 2013, and how it has evolved since its implementation.

Never Events and Medicare

The original 2008 rules from Medicare identified eight types of HACs that would cause a reduction in payment to the involved facility while eliminating the patient's financial obligation for any additional care because of them.

The list of these types of incidents included:

• Bloodstream infections caused by central line placements
• Urinary tract infections caused by catheters
• Pressure ulcers acquired while in the hospital
• Patient falls that caused injury
• Transfusions with the wrong blood type

The CMS made clear that its primary goal was patient safety, and it followed industry efforts to limit these HACs, such as those of the National Quality Forum.

The policies also aligned with efforts from the health insurance industry, individual states, and other stakeholders seeking to minimize the incidence of these events.

Despite controversy over HAC policies, a 2015 study from the Journal of the American Medical Association (JAMA) found that the original CMS policy was of some value in reducing specific HACs targeted by the Medicare payment rules.

The study results were based on data from 1,381 U.S. hospitals, focusing on four of the eight HACs and their frequency, as logged in the National Database of Nursing Quality Indicators maintained by the American Nurses Association.

The JAMA study researchers found:

• An 11% reduction in the rate of central-line bloodstream infections
• A 10% reduction in the rate of urinary tract infections caused by catheters

A separate study tracked Medicare patients from 2009 to 2015, reviewing the records of more than 8.8 million people. Initially, there were 13.4 never events per 1,000 people, but that declined after the Affordable Care Act rules covering HACs were passed, and dropped further after the HAC Reduction Program began in 2013.

HACs Tracked by Medicare

As of 2020, the CMS continued to track HACs that included:

• A foreign object (instrument) left in the body during surgery
• Transfusions with incompatible blood types and factors
• Falls, fractures, dislocations, burns, head and other injuries
• Pressure ulcers
• Diabetes-related glucose management conditions, such as coma
• Infections at surgical sites, such as after coronary artery bypass surgery
• The development of deep vein thrombosis or pulmonary embolism after orthopedic surgeries

What Facilities Comply With HAC Rules?

CMS says its HAC Medicare reimbursement policies apply to any facility seeking payment for treating people covered by Medicare.

In 2021, these types of facilities included:

• Critical care hospitals
• Rehabilitation hospitals and units
• Long-term care hospitals
• Psychiatric hospitals and units
• Children’s hospitals
• Veterans Affairs medical centers and hospitals
  

Practical Issues in Managing HACs

While healthcare providers generally support the goal of protecting their patients from HACs, it can be difficult to make decisions about their care while keeping track of their risks.

One solution may be a visual dashboard system, tested at three hospitals where a "stoplight" system of red-yellow-green coding was used to identify multiple HAC risks.

Other concerns center on the impacts on hospitals with fewer resources and those that treat low-income populations. One study found that the odds of a poor HAC score, which impacts Medicare reimbursement rates, are greater in highly diverse communities. The financial impact may limit these facilities' ability to care for patients.

"Although hospital quality of care is not intentionally segregated, its surrounding community is impacting its performance," the authors note. "Thus, policymakers need to accommodate the diversity of communities when developing pay-for-performance or merit-based initiatives."

Other issues centered on HAC program compliance include:

• Increased or unnecessary use of antibiotics, in an era of concern over antibiotic resistance
• Additional and costly testing for conditions that may have existed before facility admission
• Concerns that an infected or injured patient may be discharged too quickly and then require readmission
  

Summary

The Centers for Medicare & Medicaid Services (CMS) seeks to prevent Hospital Acquired Conditions (HACs), also known as never events, through its HAC Reduction Program. The program is designed to improve patient safety and patient care.

Its goals are achieved through several strategies, including financial penalties that apply to healthcare facilities that perform poorly when limiting these events. HAC incidents include falls, blood transfusion errors, and surgical mistakes.

While there is research evidence to suggest the HAC programs have reduced the number of never events, healthcare providers continue to work at identifying best practices to keep their facilities successful at meeting HAC standards while providing competent and cost-effective patient care.