Cover: Financial Incentives to Reduce Hospital-Acquired Infections Under Alternative Payment Arrangements

Financial Incentives to Reduce Hospital-Acquired Infections Under Alternative Payment Arrangements

Published in: Infection Control & Hospital Epidemiology, Volume 39, Issue 5 (May 2018), Pages 509-515. doi: 10.1017/ice.2018.18

Posted on Apr 20, 2018

by Catherine C. Cohen, Jianfang Liu, Bevin Cohen, Elaine L. Larson, Sherry Glied


The financial incentives for hospitals to improve care may be weaker if higher insurer payments for adverse conditions offset a portion of hospital costs. The purpose of this study was to simulate incentives for reducing hospital-acquired infections under various payment configurations by Medicare, Medicaid, and private payers.


Matched case-control study.


A large, urban hospital system with 1 community hospital and 2 tertiary-care hospitals.


All patients discharged in 2013 and 2014.


Using electronic hospital records, we identified hospital-acquired bloodstream infections (BSIs) and urinary tract infections (UTIs) with a validated algorithm. We assessed excess hospital costs, length of stay, and payments due to infection, and we compared them to those of uninfected patients matched by propensity for infection.


In most scenarios, hospitals recovered only a portion of excess HAI costs through increased payments. Patients with UTIs incurred incremental costs of $6,238 (<.01), while payments increased $1,901 (<.05) at public diagnosis-related group (DRG) rates. For BSIs, incremental costs were $15,367 (<.01), while payments increased $7,895 (<.01). If private payers reimbursed a 200% markup over Medicare DRG rates, hospitals recovered 55% of costs from BSI and UTI among private-pay patients and 54% for BSI and 33% for UTI, respectively, across all patients. Under per-diem payment for private patients with no markup, hospitals recovered 71% of excess costs of BSI and 88% for UTI. At 150% markup and per-diem payments, hospitals profited.


Hospital incentives for investing in patient safety vary by payer and payment configuration. Higher payments provide resources to improve patient safety, but current payment structures may also reduce the willingness of hospitals to invest in patient safety.

This report is part of the RAND external publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

RAND is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.