Financial incentives, such as pay-for-performance (P4P) programs, are increasingly being used to improve physician behavior. However, the impact of these programs on improving quality of care for patients have been mixed, with some studies showing modest gains and others reporting little to no improvement on quality of care measures. Furthermore, unintended consequences of P4P programs have been demonstrated, including larger financial rewards for those hospitals with higher performance at baseline and significant financial losses for hospitals that serve large minority populations. As of October 1, 2008, Medicare implemented the use of a new financial mechanism-nonpayment for preventable complications (NPCC)-which is a """"""""stick"""""""" rather than a """"""""carrot"""""""". Medicare no longer pays hospitals for treating certain healthcare-associated infections (HAIs) that arise in patients if they are not present on admission. Our proposed research is unique and timely. There are no evaluations of the impact of NPPC, which is being implemented by one of the largest payers in the U.S. Despite lack of evidence for its efficacy, it is hoped that financial disincentives will motivate hospitals and providers to focus their efforts on reducing HAIs. While the goal is certainly worthy, the mechanism being used to motivate change should be rigorously evaluated to ensure that it achieves its intended consequence without the occurrence of unintended consequences. Our research seeks to understand the impact, both positive and negative, of NPPC on health outcomes and costs. We will assess the impact of Medicare's use of NPPC on outcomes and costs in hospitals that report data to Medicare and the National Healthcare Safety Network (NHSN).
Our aims are: (1) To evaluate the impact of NPPC on HAI rates reported by Medicare (i.e. """"""""billing"""""""" rates);(2) To evaluate the impact of NPPC on HAI rates reported by NHSN (i.e. """"""""true"""""""" infection rates);(3) To explore whether NPPC reduces both """"""""billing"""""""" and """"""""true"""""""" infection rates in different types of hospitals (e.g. for-profit vs. not-for-profit) (4) To assess whether reduced reimbursement for HAIs as a result of NPPC disproportionately affects hospitals that care for a high proportion of poor or minority patients.

Public Health Relevance

Approximately 1.7 to 2 million healthcare-associated infections (HAIs) and 99,000 deaths due to HAIs occur in U.S. hospitals annually. The economic burden of HAIs is estimated at $17 to $29 billion dollars each year. Our proposed study will provide crucial information about the impact of Medicare's use of nonpayment for preventable complications (i.e. reduced reimbursement for hospitalizations associated with HAIs) on health outcomes and costs.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Project (R01)
Project #
Application #
Study Section
Health Systems Research (HSR)
Program Officer
Hagan, Michael
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Harvard Pilgrim Health Care, Inc.
United States
Zip Code
Calderwood, Michael S; Vaz, Louise E; Tse Kawai, Alison et al. (2016) Impact of Hospital Operating Margin on Central Line-Associated Bloodstream Infections Following Medicare's Hospital-Acquired Conditions Payment Policy. Infect Control Hosp Epidemiol 37:100-3
Vaz, Louise Elaine; Kleinman, Kenneth P; Kawai, Alison Tse et al. (2015) Impact of Medicare's Hospital-Acquired Condition policy on infections in safety net and non-safety net hospitals. Infect Control Hosp Epidemiol 36:649-55
van Mourik, Maaike S M; van Duijn, Pleun Joppe; Moons, Karel G M et al. (2015) Accuracy of administrative data for surveillance of healthcare-associated infections: a systematic review. BMJ Open 5:e008424
Kawai, Alison Tse; Calderwood, Michael S; Jin, Robert et al. (2015) Impact of the Centers for Medicare and Medicaid Services Hospital-Acquired Conditions Policy on Billing Rates for 2 Targeted Healthcare-Associated Infections. Infect Control Hosp Epidemiol 36:871-7
Calderwood, Michael S; Kleinman, Ken; Soumerai, Stephen B et al. (2014) Impact of Medicare's payment policy on mediastinitis following coronary artery bypass graft surgery in US hospitals. Infect Control Hosp Epidemiol 35:144-51
Patrick, Stephen W; Kawai, Alison Tse; Kleinman, Ken et al. (2014) Health care-associated infections among critically ill children in the US, 2007-2012. Pediatrics 134:705-12
Lee, Grace M; Kleinman, Ken; Soumerai, Stephen B et al. (2012) Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med 367:1428-37