CMS’ chief medical officer, Dr. , said those safety metrics were not designed to properly account for how a pandemic, with its patient surges and workforce shortages, might affect hospital systems.

“Safety, transparency, and quality of care of patients is not enhanced by the use of skewed or inaccurate data, and, in fact, could result in negative consequences for patients,” he said. “CMS wants the public to have complete trust in the data and will make data on quality available when we have a high confidence in its credibility and accuracy.”

But patient safety advocates argue CMS is letting hospitals off the hook for their pandemic performances, and many decried the loss of transparency that suppression of such data would cause.

CMS wants to keep “patients, payers, and insurers in the dark on what happened during the pandemic,” said , director of health care campaigns for the nonprofit U.S. Public Interest Research Group. She added that without penalties, hospitals won’t be forced to change ahead of the next crisis that strains health systems.

“There was no comma in the law that says, ‘Unless there’s a pandemic, you don’t have to pay these penalties,’” Kelmar said.

The proposed rule comes after CMS officials publicly acknowledged in the that progress on lowering hospital-acquired infections — such as urinary tract and staph infections, as well as bloodstream infections associated with central lines — has faltered significantly during the pandemic. Also, a May that used data from 2018 found that even before the pandemic, 1 in 4 Medicare patients were harmed in the hospital, with nearly half of such events being preventable.

The Leapfrog Group, a nonprofit patient advocacy group, estimates that a year die because of the patient safety issues measured by CMS’ ratings.

The metrics that CMS wants to suppress appear on website, formerly known as Hospital Compare. The site allows consumers to view a broad range of quality metrics for hospitals, including mortality and readmission rates. Those scores would continue to appear under the CMS proposal, but the site would not report data from what’s known as the , or “Patient Safety and Adverse Events Composite,” including how often patients had serious complications from potentially preventable medical harm, such as falls and sepsis. CMS will publicly release other safety data, although the pandemic has complicated that, too.

The penalties CMS wants to waive are issued annually through the , which was created by the Affordable Care Act. But because the PSI 90 won’t be available and CMS officials are wary of counting some other metrics skewed by the pandemic, they said penalizing hospitals, as they have done in the past, would not be reasonable.

The poorest-performing hospitals would be spared the 1% Medicare payment reductions that CMS would otherwise have applied throughout the upcoming federal fiscal year, which begins Oct. 1. CMS plans to resume the penalties in the following fiscal year, which begins in October 2023.

CMS’ proposal to pause such penalties is reasonable, said , a professor of health care management at the University of Michigan’s School of Public Health, who has on the hospital quality program. He pointed out that the metrics that underlie these financial penalties are easily skewed by variations in patient mix — such as those triggered by covid surges or lockdowns.

But , co-founder of and board president for the Patient Safety Action Network, said she’s tired of hearing hospitals talk about the administrative strain that reporting the data would create and of CMS saying that adjusting how it compares hospitals would be difficult.

“It’s a real burden if you die or lose your mom,” McGiffert said.

A 2021 KHN investigative series detailed the gaps in CMS’ oversight in tracking and holding hospitals accountable for patients who were diagnosed with covid after entering the hospital.

As the pandemic continues, the agency has not added hospital-acquired covid infections to its patient safety quality metrics, Fleisher said. Centers for Disease Control and Prevention spokesperson Martha Sharan said a joint effort of the CDC, CMS, and the National Quality Forum, a nonprofit that aims to improve patient care value, that would establish such metrics “could be a consideration after the emergency phase of the pandemic.”

The U.S. Department of Health and Human Services currently maintains of covid-19 hospital-onset data, but, as KHN previously reported, such data does not hold individual hospitals accountable. Patient safety experts say the HHS report is likely an undercount because it tracks only hospital-onset covid cases that appeared after 14 days.

Separately, CMS has yet to further regulate the private accrediting agencies that oversee the majority of U.S. hospitals, following from June 2021 that found “CMS could not ensure that accredited hospitals would continue to provide quality care and operate safely during the COVID-19 emergency” and could not guarantee safety going forward. The report cited holes in CMS’ authority to make accrediting agencies execute a special, covid-spurred infection control survey for hospitals to ensure patient safety.

Seema Verma, who served as CMS administrator under President Donald Trump, said hospital-acquired infections are a long-standing issue that covid exacerbated — and one that most Americans are unaware of when they choose where to receive care.

She called for more transparency so patients can decide which hospitals are safe for them. She also called for changes in the accreditation system, which she said is because of between the accrediting organizations’ consulting arms and the hospitals they inspect.

“The American public should have faith that the people that are doing the surveys don’t have a financial interest with the institution they are surveying,” Verma said.

Accrediting agencies have defended their practices during the pandemic, saying they worked with CMS as they could during the emergency.

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The penalties — a 1% reduction in Medicare payments over 12 months — are based on the experiences of Medicare patients discharged from the hospital between July 2018 and the end of 2019, before the pandemic began in earnest. The punishments, which the Affordable Care Act requires be assessed on the worst-performing 25% of general hospitals each year, are intended to make hospitals focus on reducing bedsores, hip fractures, blood clots, and the cohort of infections that before covid-19 were the biggest scourges in hospitals. Those include surgical infections, urinary tract infections from catheters, and antibiotic-resistant germs like MRSA.

This year’s list of penalized hospitals includes Cedars-Sinai Medical Center in Los Angeles; Northwestern Memorial Hospital in Chicago; a Cleveland Clinic hospital in Avon, Ohio; a Mayo Clinic hospital in Red Wing, Minnesota; and a Mayo hospital in Phoenix. Paradoxically, all those hospitals have five stars, the best rating, on Medicare’s website.

Eight years into the , 2,046 hospitals have been penalized at least once, a KHN analysis shows. But researchers have that the penalties are getting hospitals to improve their efforts to avert bedsores, falls, infections, and other accidents.  

“Unfortunately, pretty much in every regard, the program has been a failure,” said , a professor of health care management at the University of Michigan’s School of Public Health, who has on the program.  

“It’s very hard to capture patient safety with the surveillance methods we currently have,” he said. One problem, he added, is “you’re kind of asking hospitals to call out events that are going to have them lose money, so the incentives are really messed up for hospitals to fully disclose” patient injuries. Academic medical centers say the reason nearly half of them are penalized each year is that they are more diligent in finding and reporting infections.

Another issue raised by researchers and the hospital industry is that under the law, the Centers for Medicare & Medicaid Services each year must punish the quarter of general care hospitals with the highest rates of patient safety issues even if they have improved and even if their infection and complication rates are only infinitesimally different from those of some non-penalized hospitals.

In a statement, CMS noted it had limited ability to alter the program. “CMS is committed to ensuring safety and quality of care for hospital patients through a variety of initiatives,” CMS said. “Much of how the Hospital-Acquired Condition (HAC) Reduction Program is structured, including penalty amounts, is determined by law.”

In allotting the penalties, CMS evaluated 3,124 general acute hospitals. Exempted from the evaluation are around 2,000 hospitals. Many of those are critical access hospitals, which are the only hospitals serving a geographic — often rural — area. The law also excuses hospitals that focus on rehabilitation, long-term care, children, psychiatry, or veterans. And Maryland hospitals are excluded because the state has a different method for paying its hospitals for Medicare patients.

For the penalized hospitals, Medicare payments are reduced by 1% for each bill from October 2021 through September 2022. The total amount of the penalties is determined by how much each hospital bills Medicare.

A third of the hospitals penalized in the list released this year had not been punished in the previous year. Some, like UC Davis Medical Center in California, have gone in and out of the penalty box over the program’s eight years. Davis has been penalized four years and not punished four years.

“UC Davis Medical Center is usually within a few points of the [Hospital-Acquired Condition Reduction Program] threshold, so it’s not unusual to move in and out of the program year to year,” UC Davis Health said in an email. It said Davis ranked 38th out of 101 academic medical centers that use a system.

The Cleveland Clinic said that its satellite hospital in Avon has received awards from private groups, such as an for patient safety from the nonprofit Leapfrog Group. Both it and Cedars-Sinai touted their five-star ratings. In addition, Cedars said that overall assessment comes even though the hospital deals with large numbers of very sick patients. “This [star] rating is particularly meaningful because of the complexity of the care that many of our patients require,” Cedars said in a statement.

Other hospitals declined to comment or did not respond to emails.

The KHN analysis found that the government penalized 38 of the 404 hospitals that were both included in the hospital-acquired conditions evaluation and had received five stars for “overall quality,” which CMS calculates using . Those include not just infection and complication rates but also death rates, readmission frequencies, ratings that patients give the hospital after discharge, and hospitals’ consistency in following basic protocols in a timely manner, such as giving patients medicine to break up blood clots in the 30 minutes after they display symptoms of potential heart attacks.

In addition, 138 of 814 hospitals with the next-highest rating of four stars were docked by the program, KHN found.

Lower-rated hospitals were penalized with a higher frequency: Although just 9% of five-star hospitals were punished, 67% of one-star hospitals were.

KHN’s analysis found major discrepancies between the list of penalized hospitals and how Medicare’s Care Compare rated them for virtually the same patient safety infection rates and conditions. On the Medicare site, two-thirds of the penalized hospitals are rated as “no different than average” or “better than average” for the public safety measures CMS uses in assigning star ratings. The major differences center on the time frames for those measures and the structure of the penalty program. The Medicare website, for instance, evaluated only one year of infection rates, rather than the 18 months’ worth that the penalty program examined. And the public ratings are more forgiving than the penalties: Care Compare rates each hospital’s patient safety metric as average unless it’s significantly higher or lower than the scores of most hospitals, while the penalty program always punishes the lowest quartile.

Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, said the penalties would cause more stress to hospitals already struggling to handle the influx of covid patients, staffing shortages, and the extra costs of personal protective equipment. “It is demoralizing to the staff when they see their hospital is deemed unsafe or less safe than other hospitals,” she said.

Dr. , co-director of the Center for Health Economics and Policy at Washington University in St. Louis, said it was time for Congress and CMS to reevaluate the penalty program. “When this program had started, the thought was that we would get to zero” avoidable complications, she said, “and that hasn’t proven to be the case despite a really good effort on the part of some of these hospitals.”

She said the hospital-acquired conditions penalty program, along with other quality-improvement programs created by the ACA, feels “very ready for a refresh.”

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The number is the highest since the federal government five years ago launched the Hospital Acquired Conditions (HAC) Reduction Program, created by the Affordable Care Act. Under the program, 1,756 hospitals have been penalized at least once, a Kaiser Health News analysis found.

Look Up Your Hospital: Is It Being Penalized By Medicare?

This year, 110 hospitals are being punished for the fifth straight time.

The penalties pit hospitals against one another in a race to prevent the most infections, blood clots, cases of sepsis, bedsores, hip fractures and other complications. Each year, the quarter of general hospitals with the highest rates are punished, even if their records have improved from the previous year.

Under of sanctions, each hospital will lose 1 percent of its Medicare payments for patients discharged between last October and this September. That comes on top of other penalties created by the health care law, such as annual payment reductions for hospitals with too many patients being readmitted.

The hospital industry has protested the HAC penalties, saying the program’s design creates an arbitrary cutoff for which institutions get punished and which don’t. The American Hospital Association that only about 41 percent of the 768 hospitals penalized in 2017 had HAC scores that were statistically significantly higher than hospitals not being penalized.

“There are not statistical differences that would warrant a quarter of the hospitals in America getting a penalty,” said Nancy Foster, the association’s vice president for quality and patient safety.

Hospitals also complain that the ones that do the best job testing for infections and other threats to patients appear to be among the worst based on statistics, while their more lackadaisical peers look better than they might be.

Supporters of the punishments argue that the penalties are warranted in prodding hospitals to improve quality. The threat of losing money elevates the issue in many hospitals to the attention of directors and owners, said Missy Danforth, the vice president of health care ratings at the Leapfrog Group, a nonprofit devoted to patient safety.

“The fact that everyone’s talking about it, from front-line nurses to boards of directors, is positioning patient safety where it should be, which is at the forefront of everyone’s minds,” Danforth said.

Danforth dismissed hospital complaints that the penalties are not always fairly applied. “There’s a lot of really strong, good best practices to getting to zero on these infections,” she said.

Hospital patients suffered an avoidable injury in 9 of every 100 patient stays in 2016, about 2.7 million times, according to a from the federal Agency for Healthcare Research and Quality. Those included a bad reaction to medication, an injury from a procedure, a fall or an infection.

The frequency of complications has been dropping in hospitals. The report found an overall 8 percent decrease from 2014 to 2016. However, the report also found a jump in the numbers of bedsores and urinary tract infections in patients with catheters during that time.

The assesses penalties based on a subsection of the injuries examined in the AHRQ report. For each hospital, Medicare judges infection rates related to colon surgeries, hysterectomies, urinary tract catheters and central lines inserted into veins. Medicare also counts the number of infections of methicillin-resistant Staphylococcus aureus, or MRSA, and Clostridium difficile, known as C. diff.

Finally, the government tracks the rate of blood clots, sepsis, post-surgical wounds, bedsores, hip fractures and five other . Because the penalties will be applied as hospitals submit claims for reimbursement, the total dollar amount of penalties for each hospital will not be known until the federal fiscal year ends in September.

Medicare excludes from consideration a number of specialized hospitals: those serving children, veterans and psychiatric patients. Maryland hospitals are also exempted because the federal government gives that state leeway in how it pays hospitals. And more than 1,000 “critical access” hospitals, which are the only institutions in their area, are also excluded.

For the remaining hospitals, to the quarter of institutions with the highest HAC rates. That threshold varies slightly from year to year, and is a major reason that the number of hospitals being punished fluctuates annually. Before this, the largest number of hospitals punished was 769, two years ago.

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Read Full Story: Medicare Penalizes Group Of 751 Hospitals For Patient Injuries See Past Data: 2017 | 2016 | 2015

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More than half also were punished last year through the penalty, which was created by the Affordable Care Act and began four years ago. The program is designed as a financial incentive for hospitals to avoid infections and other mishaps, such as blood clots and bedsores.

Get The Data: See All 751 Hospitals Penalized

The penalties again fell heavily on teaching hospitals, although less than before. A third of them were punished this year, a Kaiser Health News analysis of found. Last year, the penalty was levied on nearly half of the nation’s teaching hospitals.

The 115 penalized academic medical centers this year include Denver Health Medical Center, Grady Memorial Hospital in Atlanta, The Mount Sinai Hospital in New York City, Northwestern Memorial Hospital in Chicago, Stanford Health Care hospitals in California and the University of California-San Francisco (UCSF) Medical Center, according to federal records.

“Academic medical centers serve patients with more-complex conditions who are at greater risk of hospital-acquired infections (HAIs) compared to community health care providers,” Stanford Health Care said in a written statement. “Hospitals with a high rate of immunocompromised patients will always seem to have higher HAIs.”

Hospitals that treat large proportions of low-income people also were fined more than hospitals with a more affluent patient base, the analysis found. About a third of those safety-net hospitals were penalized, roughly the same as last year.

The penalties have been controversial from the beginning. The hospital industry faults them as unfairly punishing hospitals that treat sicker patients and those that do a better job of identifying infections and other patient complications. Patient advocates say that, while not perfect, the penalties have been a valuable prod to make hospital executives consider more than the bottom line.

“The program has been very instrumental in focusing hospitals on the problems of patient safety and improved quality,” said Dr. Kevin Kavanagh, board chairman of Health Watch USA, a patient advocacy group. However, he said, the financial uncertainty created by the Republican efforts to revoke the Affordable Care Act has not helped.

“Right now it’s hard for hospitals to improve patient safety when there’s been so much turmoil in the health care market,” he said. “The hospitals have the tools and knowledge to make it better, and they should do so.”

Dr. Atul Grover, executive vice president at the Association of American Medical Colleges, said that while teaching hospitals as a group fared better than last year, “we are still disproportionately affected.”

There were 336 hospitals that lost money a year ago but were spared this time, the analysis showed. They include Barnes Jewish Hospital in St. Louis, Brigham and Women’s Hospital in Boston, Cedars-Sinai Medical Center in Los Angeles, the Cleveland Clinic, Geisinger Medical Center in Danville, Pa., Hospital of the University of Pennsylvania in Philadelphia, Intermountain Medical Center in Murray, Utah, and the University of Michigan Health System in Ann Arbor.

Medicare penalized 425 hospitals that it also had punished last year. For all the penalized hospitals, the reductions will retroactively apply to Medicare payments from the beginning of the federal fiscal year in October and through the end of September 2018. Medicare will cut by 1 percent its payments for each patient’s stay as well as the amount of money hospitals get to teach medical residents and to care for low-income people. The total amount for each hospital depends on how much they end up billing Medicare.

The factors considered in the Hospital-Acquired Condition Reduction Program from hysterectomies, colon surgeries, urinary tract catheters and central line tubes inserted into veins. It also encompasses rates of , or MRSA, and , known as C-diff. Medicare also takes into account the frequency of 10 types of in-hospital injuries, including bed sores, hip fractures, blood clots, sepsis and post-surgical wound ruptures. Together, these kinds of potentially avoidable events are known as hospital-acquired conditions, or HACs.

Some hospitals have been targeting the infections that Medicare not only penalizes but also publicizes on its website. UCSF, for instance, said it has been focused on reducing surgical site infections and C-diff cases. “We remain committed to continually decreasing infection rates to provide the highest level of care for our patients,” UCSF said in a statement.

While the Centers for Medicare & Medicaid Services had tweaked its methods for assessing payments, the hospital industry remained displeased with the core design of the penalty. Congress decreed that Medicare penalize the worst-performing quarter of general hospitals each year, guaranteeing that more than about 750 hospitals lose money every year even if they had improved their safety records.

In some cases, the difference between penalized hospitals and those that escaped punishment was negligible, said Nancy Foster, vice president for quality and patient safety at the American Hospital Association. “It’s a ‘HACidental’ payment policy,” she said. “It’s frustrating that you know that many hospitals end up getting a significant penalty when their performance is not different from other hospitals.”

Several types of hospitals are excluded from being considered for penalties. They include hospitals that treat psychiatric patients, veterans or children. Also exempted are hospitals with the “critical access” designation for being the only provider in an area. Maryland hospitals are excluded from the program because Medicare has a separate method of paying them.

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The punishments come in the third year of Medicare penalties for hospitals with patients most frequently suffering from potentially avoidable complications, including various types of infections, blood clots, bed sores and falls. This year the government also examined the prevalence of two types of bacteria resistant to drugs.

Based on rates of all these complications, the hospitals this week will lose 1 percent of all Medicare payments for a year — with that time frame beginning this past October.  While the government did not release the dollar amount of the penalties, they will exceed a million dollars for many larger hospitals. In total, hospitals will lose about $430 million, 18 percent more than they lost last year, according to an estimate from the Association of American Medical Colleges.

The reductions apply not only to patient stays but also will reduce the amount of money hospitals get to teach medical residents and care for low-income people.

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Forty percent of the hospitals penalized this year escaped punishment in the first two years of the program, a Kaiser Health News analysis shows. Those 306 hospitals include the University of Miami Hospital in Florida, Cambridge Health Alliance in Massachusetts, the University of Michigan Health System in Ann Arbor and Mount Sinai Hospital in New York City.

Nationally, hospital-acquired conditions  between 2010 and 2015, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The biggest reductions were for bad reactions to medicines, catheter infections and post-surgical blood clots.

Still, hospital harm remains a threat. AHRQ estimates there were 3.8 million hospital injuries last year, which translates to 115 injuries during every 1,000 patient hospital stays during that period.

Each year, at least 2 million people become infected with bacteria that are resistant to antibiotics, including nearly a quarter million cases in hospitals. The Centers for Disease Control and Prevention estimates 23,000 people die from them.

Infection experts fear that soon patients may face new strains of germs that are . Between prescribed in hospitals are either not needed or inappropriate, studies have found. Their proliferation — inside the hospital, in doctor’s prescriptions and in farm animals sold for food — have hastened new strains of bacteria that are resistant to many drugs.

One resistant bacteria that Medicare included into its formula for determining financial penalties for hospitals is methicillin-resistant Staphylococcus aureus, or MRSA, which can cause pneumonia and bloodstream and skin infections. outside of hospitals and sometimes people with it show no signs of disease. But these people can bring the germ into a hospital, where it can be spread by health care providers and be especially dangerous for older or sick patients whose immune system cannot fight the infection.

Hospitals have had some success in reducing MRSA infections, which between 2011 and 2014, according to the CDC. AHRQ estimates there were last year.

The second bacteria measured for the penalties is Clostridium difficile, known as , a germ that can multiply in the gut and colon when patients take some antibiotics to kill off other germs. It can also spread through contaminated surfaces or hands.

“The reality is we don’t know how to prevent all these infections,” said Dr. Louise Dembry, a professor at the Yale School of Medicine and president of the Society for Healthcare Epidemiology of America.

The Hospital-Acquired Condition Reduction Program also factors in rates of infections from hysterectomies, colon surgeries, urinary tract catheters and central line tubes. Those infections carry the most weight in determining penalties, but the formula also takes into account the frequency of bed sores, hip fractures, blood clots and four other complications.

Specialized hospitals, such as those that treat psychiatric patients, veterans and children, are exempted from the penalties, as are hospitals with the “critical access” designation for being the only provider in an area. Of the remaining hospitals, the Affordable Care Act requires that Medicare penalize the 25 percent that perform the worst on these measures, even if they have reduced infection rates from previous years.

That inflexible quota is one objection the hospital industry has with the penalties. In addition, many hospitals complain that they are penalized because of their vigilance in detecting infections, even ones that do not cause any symptoms in patients. in particular have been frequently punished.

“The HAC penalty payment program is regarded as rather arbitrary, so other than people getting upset when they incur a penalty, it is not in and of itself changing behavior,” said Nancy Foster, vice president for quality and patient safety at the American Hospital Association.

Federal records show that 347 hospitals penalized last year will not have payments reduced because their performance was better than others. Those include Harbor-UCLA Medical Center in Los Angeles, the Johns Hopkins Hospital in Baltimore and the University of Tennessee Medical Center in Knoxville.

Over the lifetime of the penalty program, 241 hospitals have been punished in all three years, including the Cleveland Clinic; Intermountain Medical Center in Murray, Utah; Ronald Reagan UCLA Medical Center in Los Angeles; Grady Memorial Hospital in Atlanta; Northwestern Memorial Hospital in Chicago; and Brigham & Women’s Hospital in Boston.

The penalties come as the Centers for Medicare & Medicaid Services also launches for hospitals to ensure that the use of antibiotics is limited to cases where they are necessary and be circumspect in determining which of the drugs are most likely to work for a given infection. Hospitals will have to establish these antibiotic stewardship programs as a condition of receiving Medicare funding under a last summer.

Lisa McGiffert, who directs Consumers Union’s Safe Patient Project, said that as a result of Medicare’s penalties and other efforts, “more hospitals are thinking more about appropriate use of antibiotics.” However, she said, “I think most hospitals do not have effective antibiotic stewardship programs yet.”

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Below are the hospitals being penalized:

Full KHN Story: Download the Year-by-Year Data: CSV| PDF

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