title: Impact of Medicare's Nonpayment Program on Hospital-acquired Conditions.
abstract: 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.
  
  
  
  To determine whether the Program was associated with changes in HAC incidence, and whether this association varies across hospitals with differential Medicare patient load.
  
  
  
  Quasi-experimental study using difference-in-differences estimation. Incidence of HACs before and after Program implementation was compared across hospital MUR quartiles.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  The Program was associated with decline in incidence of selected HACs, and this decline was variably greater among hospitals with higher MUR.
authors.affiliation: Departments of *Orthopaedics and Rehabilitation †Anesthesiology ‡Public Health Sciences, University of Rochester Medical Center, Rochester, NY §Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA.
authors.forename: Caroline P
authors.initials: CP
authors.lastname: Thirukumaran
authors.forename: Laurent G
authors.initials: LG
authors.lastname: Glance
authors.forename: Helena
authors.initials: H
authors.lastname: Temkin-Greener
authors.forename: Meredith B
authors.initials: MB
authors.lastname: Rosenthal
authors.forename: Yue
authors.initials: Y
authors.lastname: Li
mesh_terms: D016001:Confidence Intervals; D003428:Cross Infection / Q000191:economics*; D005260:Female; D006801:Humans; D015994:Incidence; D019458:Insurance Coverage / Q000191:economics*; D007902:Length of Stay / Q000191:economics*; D008297:Male; D006278:Medicare / Q000191:economics*; D009518:New York / Q000453:epidemiology; D011014:Pneumonia / Q000191:economics; D012051:Reimbursement Mechanisms / Q000191:economics; D020521:Stroke / Q000191:economics; D014481:United States; D014552:Urinary Tract Infections / Q000191:economics