Medicare will Impose Penalties for Hospital Acquired Conditions Beginning October 2014

Montrose, CO:  Beginning this fall, the Centers for Medicare & Medicaid Services (CMS) will implement Medicare payment reductions under the Hospital-Acquired Condition (HAC) Reduction Program. Under the program, hospitals that rank among the lowest-performing 25 percent will lose one (1) percent of each Medicare payment for fiscal year (FY) 2015. The scoring is based on two domains; Hospital Acquired Infections reported between Jan. 1, 2012 – Dec. 31, 2013 and nine Patient Safety Indicators reported between July 2011 and June 2013.

Domain 1:

  1. Patient safety indicators (PSI) 90 composite measure which includes: pressure ulcer rate, latrogenic pneumothorax rate, postoperative hip fracture rate, postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT), postoperative sepsis rate, wound dehiscence rate and accidental puncture and laceration rate.

Domain 2:

  1. Central-line associated bloodstream infections (CLASBI) measure
  2. Catheter-associated urinary tract infections (CAUTI) measure

Domain 1 scores; the PSI 90 measures account for 35 percent

Domain 2 scores; CLASBI and CAUTI rates account for the remaining 65 percent of a hospital’s overall HAC score and are collected by the Centers for Disease Control and Prevention through the National Healthcare Safety Network.

The preliminary Hospital Acquired Infection data, which was released in April, is based on infections during a 12-month period from July 2012 through June 2013. The final scores, which will be released later this summer, are based on a 24-month period. The preliminary data and the final scores could differ significantly.  In the case of Montrose Memorial Hospital, this difference may be substantial since the MMH Domain 2 scores were excluded from the preliminary report because the shorter time frame did not provide a large enough sample size to include in the calculation.  MMH had only one Hospital Acquired Infection during the two year reporting period which is better than the national average.

It’s important to keep in mind that the HAC Reduction Program is only one in over seventy programs that rate quality indicators in hospitals.  Each report uses significantly different methodologies and have different ratings for the same hospitals during the same time period.  Steve Hannah, CEO said “Quality and patient safety are top priorities for Montrose Memorial Hospital.  We constantly work to improve our quality of care and implement better patient safety systems.  Rating and ranking programs offer different information; however we don’t recommend you rely on any one of them completely.  We encourage people to do their research and ask the appropriate questions.”

Here are a few examples of successful quality programs MMH has been recognized for:

  • MMH participates with the Colorado Hospital Association (CHA) in a clinical excellence program funded by CMS called the Partnership for Patients campaign.  The program focuses on 11 focus areas, including four measures (CLASBI, CAUTI, pressure ulcers, and PE and DVT) that are included in the HAC Reduction Program.
    • In May 2014, MMH was recognized as a CHA HEN hospital who achieved at least a 20% reduction in readmissions.
      • Hospitals are making progress reducing avoidable readmissions by employing several effective strategies. While readmissions are the result of a variety of factors, the lack of care coordination and effective transitions of care are important contributors. Addressing complex issues across care settings is difficult and requires new tools, communication channels and care processes.
      • On June 19, 2014, MMH was informed by CMS that they had satisfactorily met the requirements for the Hospital Inpatient Quality Reporting Program and would receive the full annual market basket update for FY 2015.  These requirements are based on information available at
      • Montrose Memorial Hospital received two National Patient Satisfaction Awards from Avatar Solutions who is a leading provider of Patient Surveys.  Highlighting its consistent dedication to providing a high-quality patient experience, MMH was awarded the following honors:
        • Exemplary Service – Overall Best Performer for 2013
        • Most Improved for Medium Hospitals for Quiet at Night – 2013

The Exemplary Service, Best Performer Award distinguishes the top facilities in Avatar’s national database that have the highest overall, combined scores for Inpatient, Outpatient, Emergency Department and Ambulatory Surgery.  The award recognizes high performing facilities who demonstrate consistent patient experiences throughout the organization.  There are 310 active hospitals in the Avatar database and this award was only given to 13 hospitals nationwide.