MBAX 6332 Week 4 Stakeholder Gains and Burdens Example

Gains, Burdens and Where Each Party Pushes Its Costs: A Stakeholder Register for Medicare's Hospital-Acquired Condition Reduction Program, With Safety-Net Hospitals Given Their Own Row

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Walden University

MBAX 6332: Health Policy and Systems Thinking

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Month Day, Year

Gains, Burdens and Where Each Party Pushes Its Costs: A Stakeholder Register for Medicare's Hospital-Acquired Condition Reduction Program, With Safety-Net Hospitals Given Their Own Row

Purpose

Every party touched by the Hospital-Acquired Condition Reduction Program gains something, absorbs something or moves a cost onto someone else. This analysis enters seven parties in a register with the same four columns for each, so a reader can watch a cost leave one row and arrive in another. The vantage point is that of a hospital quality analyst in a composite regional system. Bardach and Patashnik (2020) recommend this kind of side-by-side comparison when a policy's effects depend on how different parties respond to it, which is the case here.

The Register

Table 1

Stakeholder Register for the Program

Compiled for this analysis from the program's design and published evaluations; the hospital perspective is composite.

Safety-Net Hospitals Apart

Safety-net hospitals receive their own row because the concern about the program applies to them specifically. In the program's first year, 28.3 percent of safety-net hospitals were penalized, against 19.9 percent of other hospitals (Rajaram et al., 2015). Sankaran et al. (2019) likewise found that penalized hospitals had a larger share of patients with low socioeconomic status, and warned that the program could worsen inequities. These hospitals also tend to have lower operating margins, so a 1 percent reduction in Medicare inpatient payments takes a larger share of whatever money they could have spent on improvement. Werner et al. (2008) found that safety-net hospitals improved more slowly than others on quality measures in an earlier period, which suggests a penalty may land on hospitals least able to respond to it. Folding safety-net hospitals into the hospitals row would hide all of this.

Teaching Hospitals and the Testing Question

Teaching hospitals have their own row for a different reason. They were penalized at much higher rates, 62.2 percent of very major teaching hospitals in the first year (Rajaram et al., 2015). One explanation is that they treat sicker patients; another is that they test, culture and image more, finding conditions other hospitals would miss. Their available move is political: to argue that the measure should account for surveillance intensity.

Clinicians and the Cost to Patients

The most consequential cost transfer is the least visible. When an infection counts against the hospital only if a culture confirms it, a clinician deciding whether to send a culture faces a small incentive not to. Most clinicians follow guidelines regardless, and stewardship programs rightly discourage unnecessary cultures. But at the margin, the program creates pressure in one direction, and if a needed test is skipped, the cost lands on the patient. This is the kind of unintended effect Merton (1936) described: a purposive action producing consequences its designers did not intend or foresee.

Beneficiaries, Seen From Their Side

Medicare beneficiaries are the party the program exists to protect, and the register shows that they bear little direct burden. Their gain depends on whether the program actually reduces harm, which the evidence reviewed earlier suggests it may not do beyond existing trends. They can use public scores to choose hospitals, though few patients do so in practice.

Other Payers Copying the Design

The last row is easy to overlook. Several commercial insurers and state Medicaid programs have built hospital-acquired condition measures into their own contracts, often borrowing Medicare's definitions. When they do, a hospital's score on the federal measure affects payments from more than one source, and the incentives described above, to prevent harm and also to look carefully at what gets counted, grow stronger. For a safety-net hospital that depends on Medicaid, a measure adopted by the state program can matter more than the Medicare penalty itself. The register therefore treats other payers as a party that can multiply the program's effects without having designed it, and the brief that follows considers whether its recommendation would travel to those contracts as well.

What the Register Shows

Read across the rows, the register shows that the program's costs fall most heavily on safety-net and teaching hospitals and, potentially, on patients whose tests are skipped, while its gains are diffuse. That pattern will shape the recommendation developed in the brief that follows.

References

Bardach, E., & Patashnik, E. M. (2020). A practical guide for policy analysis: The eightfold path to more effective problem solving (6th ed.). CQ Press.

Merton, R. K. (1936). The unanticipated consequences of purposive social action. American Sociological Review, 1(6), 894-904. https://doi.org/10.2307/2084615

Rajaram, R., Chung, J. W., Kinnier, C. V., Barnard, C., Mohanty, S., Pavey, E. S., McHugh, M. C., & Bilimoria, K. Y. (2015). Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program. JAMA, 314(4), 375-383. https://doi.org/10.1001/jama.2015.8609

Sankaran, R., Sukul, D., Nuliyalu, U., Gulseren, B., Engler, T. A., Arntson, E., Zlotnick, H., Dimick, J. B., & Ryan, A. M. (2019). Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: Retrospective cohort study. BMJ, 366, l4109. https://doi.org/10.1136/bmj.l4109

Werner, R. M., Goldman, L. E., & Dudley, R. A. (2008). Comparison of change in quality of care between safety-net and non-safety-net hospitals. JAMA, 299(18), 2180-2187. https://doi.org/10.1001/jama.299.18.2180