Impact of Medicare's Nonpayment Program on Hospital-acquired Conditions

Med Care. 2017 May;55(5):447-455. doi: 10.1097/MLR.0000000000000680.


Background: Medicare's Nonpayment Program of 2008 (hereafter called Program) withholds hospital reimbursement for costs related to hospital-acquired conditions (HACs). Little is known whether a hospital's Medicare patient load [quantified by the hospital's Medicare utilization ratio (MUR), which is the proportion of inpatient days financed by Medicare] influences its response to the Program.

Objective: To determine whether the Program was associated with changes in HAC incidence, and whether this association varies across hospitals with differential Medicare patient load.

Research design: Quasi-experimental study using difference-in-differences estimation. Incidence of HACs before and after Program implementation was compared across hospital MUR quartiles.

Subjects: A total of 867,584 elderly Medicare stays for acute myocardial infarction, congestive heart failure, pneumonia, and stroke that were discharged from 159 New York State hospitals from 2005 to 2012.

Measures: For descriptive analysis, hospital-level mean HAC rates by month, MUR quartile, and Program phase are reported. For multivariate analysis, primary outcome is incidence of the any-or-none indicator for occurrence of at least 1 of 6 HACs. Secondary outcomes are the incidence of each HAC.

Results: The Program was associated with decline in incidence of (i) any-or-none indicator among MUR quartile 2 hospitals (conditional odds ratio=0.57; 95% confidence interval, 0.38-0.87), and (ii) catheter-associated urinary tract infections among MUR quartile 3 hospitals (conditional odds ratio=0.30; 95% confidence interval, 0.12-0.75) as compared with MUR quartile 1 hospitals. Significant declines in certain HACs were noted in the stratified analysis.

Conclusions: The Program was associated with decline in incidence of selected HACs, and this decline was variably greater among hospitals with higher MUR.

MeSH terms

  • Confidence Intervals
  • Cross Infection / economics*
  • Female
  • Humans
  • Incidence
  • Insurance Coverage / economics*
  • Length of Stay / economics*
  • Male
  • Medicare / economics*
  • New York / epidemiology
  • Pneumonia / economics
  • Reimbursement Mechanisms / economics
  • Stroke / economics
  • United States
  • Urinary Tract Infections / economics