By Lisa Chamoff, DOTmed contributing reporter

A quarter of the nation's hospitals face a 1 percent cut in Medicare payments this fall due to comparatively high rates of patient infections and complications, and the cuts disproportionately affect teaching hospitals and facilities that serve low-income patients, according to an analysis by Kaiser Health News.

In April, the Centers for Medicare and Medicaid Services released preliminary information on which hospitals would be penalized under the Hospital-Acquired Condition (HAC) Reduction Program, based on a "hospital acquired-condition" score from 1 to 10. CMS based the scores on hospitals' rate of catheter-associated bloodstream and urinary tract infections and other patient injuries, including bedsores, blood clots, and hip fractures. They identified 761 facilities that had a score above seven, which is when the penalties kick in. That number could change since the preliminary list is based on data from July 2012 to June 2013, and the final ranking will also include performance through the second half of 2013.

The Kaiser analysis found that the biggest impact might be on major teaching hospitals, with 54 percent of those facilities set to receive penalties, versus 18 percent of non-teaching hospitals. Although CMS does consider whether a hospital is affiliated with a medical school when calculating infection rates, the Association of American Medical Colleges has raised concerns about some aspects of the program.

In a June 30 letter to CMS, Darrell Kirch, president and CEO of the AAMC wrote that the organization is concerned that some hospitals are identified as poor performers because of issues related to measurement and not because of true differences in quality of care. For example, some measures are based on claims data, and so performance can vary based on how hospital staff searches, documents, and codes for the complication, like bedsores.

"Some events are rare and therefore difficult, if not impossible, to measure in smaller samples," Kirch wrote. "Additionally, the complexity of patients and types of services provided at academic centers is considerably different than those at small hospitals. While measures are risk-adjusted, the adjustment may not account for all the variation."

The American Hospital Association has similar concerns with measurement based on claims data. Both organizations also take issue with the fact that the legislation that created the program requires that a quarter of all hospitals be penalized, even if they've taken steps to reduce infections.

"It would be like having a classroom of brilliant students and saying that at least a quarter of you have to get an 'F,' " Nancy Foster, vice president for quality and public safety at the AHA, told DOTmed News.

Foster noted that CMS has "gone out of its way to design a program as fairly as it possibly could given the legislative language they were handed."

"While we think it is absolutely fair to provide some incentive to be even safer, it is problematic for us that the measures that are used, at least this measure when it's used, is not accurately portraying our performance," Foster said.

The HAC program is the third part of the federal government's major performance-based initiatives for hospitals. The first program, which penalized hospitals with high readmission rates, did see some results. The portion of Medicare patients who were re-hospitalized within 30 days of discharge decreased to 17.5 percent in 2013, down from 18.5 percent in 2012, according to a report released by CMS in May.

"The worst offenders for readmissions have gotten a lot better," Erik Johnson, senior vice president at Avalere, a consulting and research firm that works with hospitals and health care organizations, told DOTmed News. "When CMS tells hospitals to pay attention to something, they do and they kind of get better at stuff."

Johnson said that hospital executives shouldn't think about these programs, which all encourage the same type of behavior, separately. Hospitals should get better at triaging patients and make sure patients at risk for infection are treated a little bit differently.

"Hospitals are pretty nimble," Johnson said. "The odds are that they will start to see improvements."