Enlightening Patterns of Avoidable Patient Harm in California Hospitals

As discussed last month, preventable patient harms known as HAC or hospital-acquired conditions continue to happen to nearly 1 in 10 patients in the United States despite mandates for improvement. An initial look at the current state of the state of California revealed one third of hospitals falling into the lowest quartile nationally at avoiding these infections and complications, costing them a penalty of one percent of all CMS (Centers for Medicare and Medicaid Services) reimbursement in 2020. These results hurt hospitals’ patients, reputations, and bottom lines. With estimated additional treatment costs at $31,000 per case, penalties averaging $500,000 per hospital, escalating costs to do business, and reimbursements diminishing who can afford the status quo (Agency for Healthcare Research and Quality, 2017) (Advisory Board, 2020)?

Taking a deeper look at patterns of penalized performance with the 2020 Hospital Compare data in California three concerns emerged (California Office of Statewide Health Planning and Development, 2020) (Hospital-acquired Condition Reduction Program, 2020) (Advisory Board, 2020). First, more than half of California's Level I and II Trauma Centers incurred a penalty for bottom quartile performance in HAC avoidance. Publicly controlled hospitals subsidized with tax dollars experienced similar results with 55% of city, county and district facilities falling into this lowest performing bracket. In addition, plotting performance on the map enlightened a lack in some areas of any hospital option performing above the bottom quartile in keeping patients safe from these events that should never happen. These findings sound a warning alarm for the state of California.

Level I and II Trauma Centers provide vital resources to our communities and extended areas by being constantly ready to provide immediate, comprehensive care for all injured patients. This year 53% (26 of 49) of Level I and II Trauma Centers fell into the bottom quartile in avoiding these preventable patient harms, costing an estimated average loss in CMS reimbursement of $915,000 for these facilities. Of the Level I Trauma Centers providing vital training for our next generation of physicians two-thirds were penalized for low performance (10 of 15). These trauma and teaching centers often provide specialized treatment to complex populations with cutting edge research and life saving technologies unavailable elsewhere with expert physicians and/or teams of physicians in various levels of training.

Over half (21 of 38) of publicly held hospitals exhibited bottom quartile results in HAC avoidance. These results cost them a loss of one percent of their total CMS reimbursement for 2020, around $370,000 on average for these specific entities. City, county and district controlled hospitals receive tax dollar subsidies to ensure access to necessary services for their communities which would be otherwise underserved. Public control conditions often exist because of low levels of reimbursement related to large percentages of uninsured and underinsured community populations. This suggests compounded financial hardships on patients and communities. Uninsured and underinsured patients may be less able to afford their share of inpatient and outpatient costs to treat these avoidable infections and complications. In addition, the lost reimbursement of CMS penalty and increased costs to treat HAC incurred by the hospital further burden the public health budget already subsidizing care in these underserved communities.

Looking at a map of the state of California provides visual realization of the wide ranging areas needing hospital services, from many highly populated urban densities to vast farmlands to areas isolated by treacherous terrain. When analyzing locations of penalized hospitals against total hospitals in an area on the map it becomes apparent that some communities do not have adequate or any choice of hospitals performing above the bottom quartile in avoiding HAC. There were two patterns seen. Certain agricultural areas have very few hospitals with all options available in the penalty. Some cities adjacent to large, isolated areas of the state have the vast majority of hospital beds in medical centers performing in the bottom quartile at keeping patients safe from events that should never happen. In contrast, while urban areas have pockets of low performing hospitals, safer options exist nearby provided patients have the resources to access them.

These patterns of low performance related to trauma centers, publicly subsidized hospitals, and geographical locations pose a question; should additional patient harm and financial loss associated with HAC be considered an acceptable side effect of needing care in a specialized setting for complex needs, or care to for marginalized communities? Of course not. By shedding light on specific pockets of vulnerability to low performance by examining the data, California's leaders can focus efforts to make meaningful improvements for patients and measurable financial impact for our communities and hospitals. Hospital-acquired conditions should not be viewed as a side effect or inevitable outcome, even for subsets struggling to stay out of the bottom quartile. By adding expertise in avoiding infections and complications into these complex environments, much patient suffering and financial loss could be avoided. California has excellent examples of Level I and II Trauma Centers, county and district hospitals, and hospitals in isolated areas performing well at keeping patients safe from these Never Events. Let’s work together to bring the safest care to all patients in California by first Doing No Harm.

Congratulations to some exemplars of best in class performance in avoiding HAC for 2020:

Level I Trauma Centers

• University of California Irvine Medical Center

• Santa Barbara Cottage Hospital

Level II Trauma Centers

• Memorial Medical Center (Modesto)

• Enloe Medical Center (Chico)

• John Muir Medical Center- Walnut Creek

• Sutter Roseville Medical Center

• Henry Mayo Newhall Hospital (Los Angeles)

City, County, or District Controlled Hospitals

• Rancho Los Amigos National Rehabilitation Center (Los Angeles County)

• Arrowhead Regional Medical Center (San Bernardino County)

• San Mateo Medical Center (San Mateo County)

• El Camino Hospital Mountain View (District)

• Marin Health Medical Center (District)

Isolated Area Hospitals

• Sutter Coast Hospital (Crescent City)

• Adventist Health Ukiah Valley

Advisory Board. Map: The 786 hospitals facing HAC penalties in 2020. Feb. 3, 2020. https://www.advisory.com/daily-briefing/2020/02/03/hac-penalties

Agency for Healthcare Research and Quality, Rockville, MD. Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions. Content last reviewed November 2017. https://www.ahrq.gov/hai/pfp/haccost2017.html

California Office of Statewide Health Planning and Development. (2020). Report Center. https://reports.siera.oshpd.ca.gov/

Hospital-Acquired Condition Reduction Program. (2020). U.S Centers for Medicare and Medicaid Services. https://www.medicare.gov/hospitalcompare/HAC-reduction-program.html