Skip to main content

Impact of Medicare’s Hospital-Acquired Condition Policy on Infections in Safety Net and Non–Safety Net Hospitals

  • Louise Elaine Vaz (a1), Kenneth P. Kleinman (a2), Alison Tse Kawai (a2), Robert Jin (a2), William J. Kassler (a3), Patricia S. Grant (a4) (a5), Melisa D. Rett (a2), Donald A. Goldmann (a6) (a7), Michael S. Calderwood (a2) (a8), Stephen B. Soumerai (a2) and Grace M. Lee (a2) (a6)...

Policymakers may wish to align healthcare payment and quality of care while minimizing unintended consequences, particularly for safety net hospitals.


To determine whether the 2008 Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy had a differential impact on targeted healthcare-associated infection rates in safety net compared with non–safety net hospitals.


Interrupted time-series design.


Nonfederal acute care hospitals that reported central line–associated bloodstream infection and ventilator-associated pneumonia rates to the Centers for Disease Control and Prevention’s National Health Safety Network from July 1, 2007, through December 31, 2013.


We did not observe changes in the slope of targeted infection rates in the postpolicy period compared with the prepolicy period for either safety net (postpolicy vs prepolicy ratio, 0.96 [95% CI, 0.84–1.09]) or non–safety net (0.99 [0.90–1.10]) hospitals. Controlling for prepolicy secular trends, we did not detect differences in an immediate change at the time of the policy between safety net and non–safety net hospitals (P for 2-way interaction, .87).


The Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy did not have an impact, either positive or negative, on already declining rates of central line–associated bloodstream infection in safety net or non–safety net hospitals. Continued evaluations of the broad impact of payment policies on safety net hospitals will remain important as the use of financial incentives and penalties continues to expand in the United States.

Infect Control Hosp Epidemiol 2015;00(0): 1–7

Corresponding author
Address correspondence to Louise Vaz, MD, MPH, Doernbecher Children’s Hospital, Oregon Health & Science University, Mail Code CDRC-P, 707 SW Gaines St, Portland, OR 97239 (
Hide All
1. Stone, PW. Economic burden of healthcare-associated infections: an American perspective. Expert Rev Pharmacoecon Outcomes Res 2009;9:417422.
2. Reed, D, Kemmerly, SA. Infection control and prevention: a review of hospital-acquired infections and the economic implications. Ochsner J 2009;9:2731.
3. Zimlichman, E, Henderson, D, Tamir, O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173:20392046.
4. Stone, PW, Pogorzelska-Maziarz, M, Herzig, CT, et al. State of infection prevention in US hospitals enrolled in the National Health and Safety Network. Am J Infect Control 2014;42:9499.
5. Berenholtz, SM, Lubomski, LH, Weeks, K, et al. Eliminating central line–associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol 2014;35:5662.
6. Department of Health and Human Services. Prevent health care–associated infections (HAIs) | (ODPHP). Webpage. 2014. Available at: Accessed March 5, 2014.
7. Pronovost, PJ, Marsteller, JA, Goeschel, CA. Preventing bloodstream infections: a measurable national success story in quality improvement. Health Aff 2011;30:628634.
8. Pronovost, P, Goeschel, C, Colantuoni, E, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 2010;340:c309.
9. Straube, B, Blum, JD. The policy on paying for treating hospital-acquired conditions: CMS officials respond. Health Aff 2009;28:14941497.
10. Centers for Medicare and Medicaid Services. CMS overview: hospital-acquired conditions (present on admission indicator). Webpage. 2014. Available at: Accessed May 22, 2014.
11. Institute of Medicine. America’s Health Care Safety Net: Intact but Endangered. Washington, DC: National Academies Press, 2000:116.
12. Ly, DP, Lopez, L, Isaac, T, Jha, AK. How do black-serving hospitals perform on patient safety indicators? Med Care 2010;48:11331137.
13. Werner, RM, Goldman, LE, Dudley, RA. Comparison of change in quality of care between safety-net and non–safety-net hospitals. JAMA 2008;299:21802187.
14. Hoff, T, Hartmann, CW, Soerensen, C, Wroe, P, Dutta-Linn, M, Lee, G. Making the CMS payment policy for healthcare-associated infections work: organizational factors that matter. J Healthc Manag 2011;56:319335.
15. Krein, SL, Kowalski, CP, Hofer, TP, Saint, S. Preventing hospital-acquired infections: a national survey of practices reported by US hospitals in 2005 and 2009. J Gen Intern Med 2012;27:773779.
16. Brown, J, Doloresco, F III, Mylotte, JM. “Never events”: not every hospital-acquired infection is preventable. Clin Infect Dis 2009;49:743746.
17. Lee, TB, Montgomery, OG, Marx, J, Olmsted, RN, Scheckler, WE. Recommended practices for surveillance: Association for Professionals in Infection Control and Epidemiology (APIC), Inc. Am J Infect Control 2007;35:427440.
18. Centers for Disease Control and Prevention. CDC—tracking infections in acute care hospitals/facilities—NHSN. Webpage. 2014. Available at: Accessed July 28, 2014.
19. Harvard Pilgrim Health Care Institute. The PAICAP Project | Preventing Avoidable Infectious Complications by Adjusting Payment. Webpage. 2014. Available at: Accessed March 12, 2014.
20. Lee, GM, Kleinman, K, Soumerai, SB, et al. Effect of nonpayment for preventable infections in US hospitals. N Engl J Med 2012;367:14281437.
21. Centers for Medicare and Medicaid Services. Inpatient PPS disproportionate share hospital. Webpage. 2013. Available at: Accessed December 15, 2013.
22. Centers for Disease Control and Prevention. CDC—about NHSN. Webpage. 2013. Available at: Accessed August 23, 2013.
23. Centers for Medicare and Medicaid Services. Overview page for the Acute Inpatient PPS. Webpage. 2013. Available at: Accessed March 12, 2014.
24. American Hospital Association. American Hospital Association annual survey database fiscal year 2009. 2009. Available at: Accessed June 1, 2014.
25. Centers for Medicare and Medicaid Services. Fiscal year (FY) inpatient prospective payment system (IPPS). MLN Matters 2008;MM6189:1-28. Available at: Accessed February 15, 2015.
26. Horan, TC, Andrus, M, Dudeck, MA. CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309332.
27. Meddings, J, Saint, S, McMahon, LF. Hospital-acquired catheter-associated urinary tract infection: documentation and coding issues may reduce financial impact of Medicare’s new payment policy. Infect Control Hosp Epidemiol 2010;31:627633.
28. Centers for Medicare and Medicaid Services. Special treatment: hospitals that serve a disproportionate share of low-income patients. Fed Regist 2010;412:590595.
29. Centers for Medicare and Medicaid Services. MEDPAR data set. Website 2009. Available at: Accessed March 12, 2014.
30. Centers for Medicare and Medicaid Services. Historical impact files for FY 2009. Webpage. 2009. Available at: Accessed March 12, 2014.
31. Chatterjee, P, Joynt, KE, Orav, EJ, Jha, AK. Patient experience in safety-net hospitals: implications for improving care and value-based purchasing. Arch Intern Med 2012;172:12041210.
32. Jha, AK, DesRoches, CM, Shields, AE, et al. Evidence of an emerging digital divide among hospitals that care for the poor. Health Aff 2009;28:w1160w1170.
33. Clarke, S, Donaldson, N. Nurse staffing and patient care quality and safety. In: Hughes RG ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality, 2008, Available at: Accessed January 20, 2015.
34. SAS Institute. SAS (version 9.4) statistical software. Cary, NC; 2014.
35. McNair, PD, Luft, HS, Bindman, AB. Medicare’s policy not to pay for treating hospital-acquired conditions: the impact. Health Aff 2009;28:14851493.
36. Essential Hospitals. Hospital-acquired infections (HAI) archives | America’s Essential Hospitals. Webpage. 2014. Available at: Accessed June 18, 2014.
37. Calderwood, MS, Kleinman, K, Soumerai, SB, et al. Impact of Medicare’s payment policy on mediastinitis following coronary artery bypass graft surgery in US hospitals. Infect Control Hosp Epidemiol 2014;35:144151.
38. Naessens, J. Identifying adverse events not present on admission: can we do it? AHRQ Perspective. Webpage. 2008. Available at: Accessed June 30, 2014.
39. Harris, JM, Gay, JC, Neff, JM, Patrick, SW, Sedman, A. Comparison of administrative data versus infection control data in identifying central line–associated bloodstream infections in children’s hospitals. Hosp Pediatr 2013;3:307313.
40. Johnson, T, Kane, JM, Odwazny, R, McNutt, R. Association of the position of a hospital-acquired condition diagnosis code with changes in Medicare severity diagnosis-related group assignment. J Hosp Med 2014;9:707713.
41. McNutt, R, Johnson, TJ, Odwazny, R, et al. Change in MS-DRG assignment and hospital reimbursement. Qual Manag Heal Care 2010;19:1724.
42. Lee, GM, Hartmann, CW, Graham, D, et al. Perceived impact of the Medicare policy to adjust payment for health care–associated infections. Am J Infect Control 2012;40:314319.
43. Hartmann, CW, Hoff, T, Palmer, JA, Wroe, P, Dutta-Linn, MM, Lee, G. The Medicare policy of payment adjustment for health care–associated infections: perspectives on potential unintended consequences. Med Care Res Rev 2012;69:4561.
44. Coughlin, TA, Long, SK, Sheen, E, Tolbert, J. How five leading safety-net hospitals are preparing for the challenges and opportunities of health care reform. Health Aff 2012;31:16901697.
45. Summer, L. The Impact of the Affordable Care Act on the Safety Net. Washington, DC: Academy Health, 2011:16. Available at:
46. Bachrach, D, Braslow, L, Karl, A, Bruce, S. Toward a High Performance Health Care System for Vulnerable Populations: Funding for Safety-Net Hospitals Prepared for the Commonwealth Fund Commission on a High Performance Health System. The Commonwealth Fund. Website. 2012. Available at: Accessed February 14, 2015.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 11
Total number of PDF views: 130 *
Loading metrics...

Abstract views

Total abstract views: 581 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 23rd March 2018. This data will be updated every 24 hours.