I was both pleased and proud to read yesterday’s letter in the Courier-Journal by Ken Marshall, President of University of Louisville Hospital, recommitting to a higher quality of medical care for our community, including its most vulnerable citizens. Alas, under the clinical and management captivity by Catholic Health Initiatives and KentuckyOne Health, the hospital has performed unfavorably in virtually every quality-comparison with other hospitals, including other teaching and safety-net hospitals. Indeed, major layoffs of clinical and support staff by KentuckyOne, and concerns about quality of care by some staff physicians drew Federal attention that threatened the Hospital’s accreditation.
Various of the many items measured and methodologies used by the numerous evaluating entities have been criticized, and in my opinion sometimes rightly so. After all, what constitutes quality? One major criticism of current federal and proprietary hospital quality assments is that they do not adequately take into consideration the socio-economic status or severity of illness in the patient populations served. With all the valid current emphasis on the nonmedical determinants of health care status and outcomes, how can we not take these into consideration? Nevertheless, for University Hospital there is nowhere to go but up. Continue reading “University of Louisville Hospital Pledges To Do Better.”
Not everyone is happy, but Kentucky doing better than the rest!
Yesterday, the Centers for Medicare & Medicaid Services (CMS) released its first iteration of a new and simplified method of presenting the results of the awkwardly named HCAHPS survey that is administered to patients after their discharge. The survey is intended to capture the patients’ own perceptions of their hospital experience and it is now part of the larger CMS Hospital-Compare initiative. As with previously released quality and safety initiatives, the reaction of individual hospitals is mixed.
The survey of 32 questions is administered to randomly selected adult patients who are between 48 hours to 6 weeks after being discharged alive from acute-care Medicare hospitals. Unlike most other quality and safety programs managed by CMS, individual patient participants are not limited to the Medicare or Medicaid programs. Hospitals attempt to reach a target of 300 surveys per year by telephone or mail, but some smaller hospitals struggle to do this. Additionally, hospitals that are exempt from having to submit the more objective Medicare process and outcome measurements (including Medicare’s Critical Access Hospitals) can participate voluntarily in this patient experience program.
Hospitals have been submitting this information voluntarily since 2006, it has been mandatory since 2007, and the results have been reported publically since 2008. A similar program for nursing homes and a few other healthcare providers already exists. Future plans are to include these patient experience scores with the other more blood-and-guts process and outcome measures to provide a single global star-score for all Medicare hospitals. Proprietary quality and safety organizations are already doing this. Continue reading “Medicare Releases New 5-Star Rating System for Acute Care Hospitals.”
Some Hospitals Get the Triple Whammy.
It can’t be easy to be a hospital administrator nowadays. It probably never was. It has always been a delicate balance to juggle dealing with the feelings and physical needs of the sick and their families, courting professional staff members, the business priorities of the community, the never ending march of new technologies, the ever-present possibility of malpractice suits, labor and staffing issues, competition from other hospitals, the spiraling costs of healthcare, and more recently the expanding expectation of transparency and measurable outcomes. There are few industries subject to as much regulation and oversight as the hospital industry. With the authority of the federal government behind it, Medicare– whose lead is followed by much of the private-payer world– is arguably the regulator-in-chief and is increasingly more willing to use its control of the purse strings to advance public health policy priorities. Highly visible in the last three years are Medicare programs that seek to change the metric for payment of hospitals from paying for volume and procedures to quality, value, and desirable health outcomes. Measurement of these latter is now being tied to Medicare hospital payments. Continue reading “All But 2 Kentucky Hospitals Receive Medicare Penalties for Quality.”
HAC Reduction Program: How valid is the evaluation construct?
Perhaps not so much.
An increasing number of private organizations attempt to measure the quality and safety of hospital care. I have already expressed my growing concern about the validity and utility of such ratings which seem to have lives of their own. Hospitals are spending a fortune to collect and report on a variety of ever-changing indicators and to improve their ratings. When the scores are good, hospitals use them to market their services. When scores are not-so-good, hospitals either make no public comment, criticize the system, or offer putative explanations why their hospitals face greater challenges than others. This selective use of quality scores in advertising has always seemed a little hypocritical to me. Is it immaterial that a hospital can be ranked as both worst and the best of something at the same time? Things are not that compartmentalized within hospitals. Continue reading “Behind the Acquired Hospital Condition Data Curtain.”
I have been interested in attempts to measure the quality and safety of healthcare since my year of fellowship on the Senate Finance Committee which oversees the Medicare program. In the run-up to what would become Medicare’s Hospital Compare program, a long list of things that might be measured was proposed. Most were set aside because of concerns about utility, comparability, reliability, difficulty of collection, or ability to be gamed. The shorter list evolved into the current iteration of Medicare’s own Hospital Compare database that is incorporated into virtually every proprietary hospital rating system. The quality measurements are part of a new payment structure that hopes to pay for quality and value instead of volume alone. Continue reading “Hospitals Penalized by Medicare for Excessive Hospital-Acquired Conditions.”
Kudos to my colleagues at University Hospital.
I recently wrote about the disappointing representation of Kentucky’s hospitals in this year’s 2015 version of US News & World Reports list of Best Hospitals. Of Kentucky’s approximately 130 acute-care hospitals for adults, not a single one achieved national ranking in any of 16 different specialties. Nine Kentucky Hospitals were designated as a “Best Regional Hospital” by having one or more of 16 specialty services considered “high-performing” as defined by scoring in the top quarter of all eligible hospitals for that specialty nationally.
I went on to discuss what are in my opinion some of the difficulties and shortcomings of current attempts to rank hospitals for quality and safety. I reinforced US News’s stated intent that their program was designed to identify hospitals best suited for the most difficult cases where the services of large, high-volume teaching hospitals with abundant in-house technology might make a difference. Hospitals not on their lists may still provide high quality routine care. With a focus on cardiology and cardiac surgery, I also discussed how the mix of data elements examined can boost or diminish a given hospitals standing [and perhaps even add fuel to the current technology arms-race among hospitals]. Continue reading “University of Louisville Hospital Designated as Best Regional Hospital for Cancer in Louisville.”
U.S. News & World Report (USNWP) recently released its newest iteration of “Best Hospitals 2014-15.” It did not take long for hospitals around the country to begin to use that newsmagazine’s endorsement in their marketing materials, including offering licensing and advertising fees to USNWP for the privilege. Readers of this health policy series of are aware of my unaltered position on the importance of transparency and accountability in our national system of medical care. However, you should also be aware of my increasing skepticism that existing attempts to distill complex clinical or medical financial information into simple icons or letter grades to represent safe or quality medical care are not yet ready for prime time. Indeed, by themselves, such “ratings” can be unhelpful or even misleading in assisting an individual to select a hospital for a specific need. In Kentucky we have seen previously highly-rated services shut down when the facts on the ground were revealed. Continue reading “U.S. News & World Report’s Best Hospitals— Do we have any in Kentucky?”
St. Joseph’s London Hospital has notified the state that it will no longer perform coronary artery bypass graft surgery (CABG), the traditional open-chest cardio-thoracic surgical procedure used to restore blood flow to the heart of people with severe coronary artery atherosclerosis. Before the advent of the the less invasive angioplasty and stenting, CABG was the main surgical approach to re-vascularization of a diseased heart. For certain combinations of coronary artery disease, and in some clinical settings, CABG remains the preferred approach today.
Why fewer invasive procedures?
In Kentucky, the frequency of both angioplasty and CABG have been gradually decreasing, presumably because the effectiveness of aggressive medical therapy is better recognized, and because research showed that the invasive approaches were being used in circumstances where they offered no advantage over non-invasive treatment. Treatment of coronary artery disease is lucrative for hospitals and physicians alike which unfortunately caused some to stretch the envelope beyond what could be justified medically, even to the point of fraud. That bubble is bursting and accounts for a some if not much of the overall decrease in invasive procedures.
Where will patients go?
The new plan in London is to transfer those patients requiring emergency surgery to one of the nearer hospitals capable of treating such a patient, presumably Pikeville, Hazard, Corbin, Asheville, Summerset, or Lexington. (Some of these hospitals perform fewer CABGs than in London!) For non-emergency surgery, patients will be referred to another KentuckyOne hospital– St. Joseph’s Lexington. Angioplasty and stenting will continue to be performed at St. Joseph’s London presumably with safeguards in place to make sure that the most appropriate procedure will be offered for medical reasons and not for convenience. Continue reading “St. Joseph’s London Discontinues Coronary Artery Bypass Surgery.”
Further consideration of recent Leapfrog Hospital Safety Scores.
Earlier this month I offered a preliminary description of the third iteration of Leapfrog’s Hospital Safety Scores for Kentucky’s hospitals. I continued to be concerned about the large and increasing number of Kentucky Hospitals that escape evaluation, including some that should be looked at the hardest. Of the 45 hospitals that were evaluated this round, one quarter saw their scores change one way or another. Two of Louisville’s four hospital systems saw their scores fall one letter grade to as low as a D, and none received an A.
Hospital reaction and criticism.
Hospitals that do well are happy. Those who do not may understandably make an effort to mitigate the adverse publicity. Jewish Hospital and St. Mary’s Healthcare (which received a D) raised an objection we have heard before– that the playing field is not level. Is it true that hospitals that do not participate with Leapfrog’s proprietary and totally optional hospital survey are at a disadvantage? Leapfrog says no– hospitals are not penalized for having empty boxes in the evaluation matrix. What happens is that all the other items (mostly obtained from the Medicare Compare database) are simply counted more heavily. KentuckyOne also argued that the data on which the scores are based is outdated. (Who is to say that newer data will not be worse than the old!) I think both these arguments deserve consideration but in my opinion fail to explain the drop in scores for two Louisville Hospitals. After all, only a handful of hospitals in Kentucky participate with Leapfrog. Whether a hospital benefits or not probably depends more on how good their performance on the survey is. Yes, the data on which the scores are based will probably be more that a year old, but virtually all Kentucky hospitals are in the same boat with respect to timeliness of data and Leapfrog participation. The Kentucky playing field, at least, is pretty level! I will provide examples from selected hospitals to illustrate this discussion. Continue reading “Safety of Louisville Hospitals: Are we there yet?”
Doing not so good? Blame the test.
On May 8, the Leapfrog group released the third iteration of its Hospital Safety Scores. The first appeared in June 2012, and the second in November. I have expressed concerns about the value to curious professionals and consumers alike because of things like volatility of scores over the short term, lack of inclusion of the many small hospitals in the state, and lack of correlation with safety scores proposed by other organizations. Nonetheless, the Leapfrog Group was one of the earliest to push for public disclosure of hospital safety parameters and its evaluation deserves to be taken seriously. I will break out the data underlying the scores and compare it to last November’s in more detail later, but for the time being, here is a raw count of the results for Kentucky hospitals.
Continue reading “Leapfrog Hospital Safety Scores Released: Third Iteration.”