MBAX 6332 Week 6 Policy Recommendation Post Example

Week 6 Discussion: Sharing a Policy Recommendation

Report Testing Intensity Beside Infection Counts: Taking a Hospital Penalty Recommendation to Classmates in a Nursing Facility, a Health Plan and a Physician Practice

I recommend that Medicare publish each hospital's testing intensity, meaning its rates of blood culturing and C. difficile testing, beside its infection measures in the Hospital-Acquired Condition Reduction Program, and study whether infection scores should account for it.

Here is the case in three sentences. The program penalizes the worst-scoring quarter of hospitals each year, and its infection measures count only infections that tests confirm, so hospitals that test more can look worse (Haut & Pronovost, 2011). The first year's penalties landed disproportionately on large teaching centers, places that culture and scan more, and on safety-net hospitals (Rajaram et al., 2015). And a large study found that receiving a penalty was not followed by measurable improvement in hospital-acquired conditions, readmissions or deaths (Sankaran et al., 2019), which raises the question of what the penalty is actually measuring.

My brief proposed this as a comment from a state hospital association on the annual Medicare payment rule. It would not require new law, since the agency controls how the measures are presented.

I am less interested in whether you agree than in how a version of this would land where you work. Three of you are in settings with similar measures:

Janine, in your skilled nursing facility, would reporting how thoroughly residents are assessed for pressure injuries at admission change how your star rating is read?

Darnell, in your health plan, would a testing-intensity figure be useful when you set hospital contract terms, or would it add a number nobody uses?

Marcus, in your physician practice, is there a screening measure where the practices that screen more look worse, and has anyone proposed reporting how much screening was done?

Reply to Darnell

Darnell, your point that contract managers already ignore half the measures they receive is fair, and it makes me want to narrow the recommendation. Perhaps testing intensity should be published only where it changes the picture: for example, flagged when a hospital's infection count is low and its testing rate is in the bottom tenth. Campbell (1979) cautioned that indicators carrying high stakes get gamed, and a flag of that kind would make one distortion visible without adding another full measure to read. Would a flag like that be more useful to your team than a full table?

Reply to Janine

Janine, thank you for explaining that your facility already records whether a pressure injury was present at admission, and that thorough admission skin checks have actually helped your rating by moving injuries into the present-on-arrival column. That is an important difference from the hospital program, where looking harder mostly adds to the count rather than shifting it. It suggests the problem I described is specific to measures that count only what is found after admission without crediting what is found on arrival. Does your rating ever penalize a facility for finding injuries that developed after admission because staff look more often?

References

Campbell, D. T. (1979). Assessing the impact of planned social change. Evaluation and Program Planning, 2(1), 67-90. https://doi.org/10.1016/0149-7189(79)90048-X

Haut, E. R., & Pronovost, P. J. (2011). Surveillance bias in outcomes reporting. JAMA, 305(23), 2462-2463. https://doi.org/10.1001/jama.2011.822

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