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<\/a>Kentucky’s Hospitals have not done well in the past on national Hospital Rankings including the Leapfrog Hospital Safety Score.\u00a0 Things seem to be getting worse. In the most recent iteration<\/a> last month, once again Kentucky had fewer ‘A’-rated hospitals than the national median and more hospitals rated near the bottom with increasing numbers of ‘D’s. \u00a0More troublesome is the observation that 5 of the 6 hospitals receiving a ‘D’ are in the same hospital system. Three of these are in Louisville including two of our major teaching hospitals.<\/p>\nI am not the first to have concerns that the push by payers of medical care to “pay for quality,” based as it is on current measures, may not be ready for prime time. Hospitals are now being penalized for low quality services, readmissions, and other factors related to efficiency and quality. \u00a0It is starting to hurt. \u00a0As I type this, Congress is considering a vote to protect some hospitals<\/a> against such cuts in their important Medicare payments if they serve more than average numbers of indigent patients and those of lower socioeconomic status. \u00a0Care must be taken that this initiative, lobbied heavily by hospital organizations and their partners in academic medicine, is not interpreted to imply that is it acceptable to provide medical care of lower quality to poor people or in teaching hospitals. The fact that this protection is being considered at all is a tacit admission that our current methods of measuring quality and safety are flawed. It is based on the assumption that socioeconomic status is independently associated with overall poorer outcomes.\u00a0 I believe the association is real, but the reasons for the disparity remain uncertain or ignored.<\/p>\n Can we recognize quality when we see it?<\/strong> What prompted this article.<\/strong> Not enough ‘A’s and too many ‘D’s.<\/strong> As a whole, Kentucky did not do very well. We are in the lower quartile for ‘A’s and the upper quartile for ‘D’s. \u00a0Some 21.2% of hospitals received 11 ‘A”s \u2013 less than the national 31%.\u00a0 At the other What is going on? \u00a0<\/strong> Many hospitals already excused.<\/strong> Are there underlying problems?<\/strong> Certainly University Hospital is in the middle of a sea change. \u00a0It was reported yesterday that Ken Marshall, its President for the duration of the partnership with KentuckyOne, is leaving his position.\u00a0 I have always liked and respected him and he is also well thought of by senior clinical faculty. \u00a0The Department of Obstetrics and Gynecology continues to navigate the impossible (in my opinion) waters between the rules of the Catholic Church and contemporary academic medicine with an interim Chair. \u00a0The former Executive Vice President for Medical Affairs is currently under federal investigation and out of the picture.\u00a0 Our University President is embattled to say the least, and the Board of Trustees of the University is rendered impotent by lack of action<\/a> by the Governor for reasons that I cannot fathom. \u00a0“Rudderless University” are the words that come to my mind as I write this.\u00a0 No matter how capable interim leadership is, it is handicapped by uncertainty and deserving of more attention and support than it is getting.<\/p>\n What happened to the money?<\/strong> Peter Hasselbacher, MD Can anyone offer better news? Have I been mislead? I would like to be accurate.<\/p>\n <\/p>\n <\/p>\n
\nA year or so ago I looked hard at the ways a number of organizations purported to measure the quality or safety of medical care<\/a>.\u00a0 I found unacceptable variation in a single hospital’s ratings among different raters at the same time, or by the same rater over relatively short intervals.\u00a0 I was troubled by the commercial nature of some of the evaluations. [There is money to be made by licensing the use of good ratings for marketing purposes by both hospitals and raters.]\u00a0 It almost seemed that any hospital could find some organization willing to call it “best.” \u00a0On the gestalt level, based on my own experience, the scores did not always agree with my expectations or were frankly unbelievable.\u00a0 Other policy experts with more experience than I were saying similar things. Nonetheless, this fabulously expensive system is not going to go away soon. We will have to work with it as it evolves to something better.<\/p>\n
\nI recently received notice that the Leapfrog Group was publishing its Spring rating of hospital safety.\u00a0 This influential and credible organization was begun by large employers and their benefit plans that wanted their insurance premium dollars to be put to better use.\u00a0 The ranking uses a combination of measures including Medicare quality items and proprietary ones. Because it has been a while since I took a look, and because of very troublesome things I was hearing about our hospitals in Louisville, I downloaded the current numbers.\u00a0 I was frankly shocked.<\/p>\n
\nYou can take a look at Leapfrog’s own website for the letter scores and the source information behind them.\u00a0 I prepared a summary<\/a> of the number of hospitals scored in each state together with the number and percent of hospitals with either an ‘A’, or ‘D’. \u00a0In general, states with a higher number of ‘A’s had lower numbers of ‘D’s but this was not simply an arithmetic offset. \u00a0I was a little surprised that 31% of all scores were ‘A.’\u00a0 This seems a little like “grade inflation” to me.\u00a0 Only 15 hospitals got an ‘F.’ (We had one in Kentucky last time.) \u00a0I also prepared an interactive map<\/a> labeled with the number of scored hospitals in each state and shaded by the percent of ‘A’s. \u00a0Hovering over each state reveals the percent of the three scores mentioned above. (Static map here<\/a>.)<\/p>\n![\"d-scores-ky-2016\"](\"http:\/\/www.khpi.org\/blog\/wp-content\/uploads\/2016\/06\/d-scores-ky-2016-96x150.jpg\")
<\/a>end of the spectrum, 11.5% of our hospitals received a ‘D.’\u00a0 Most unexpected and disappointing was that not only are there are no “A” hospitals in Louisville, but the city has 3 of the 6 hospitals at the very bottom<\/a> of the list.\u00a0 The hospitals with ‘D’s were not the small rural hospitals that we are told are in financial trouble, but are major urban hospitals in Louisville, Lexington, and Somerset.\u00a0 Troublingly, 5 of the 6 overall are KentuckyOne Health hospitals including Jewish Hospital, Sts. Mary and Elizabeth, and University Hospitals in Louisville; and the two St. Joseph Hospitals in Lexington. A concentration of low-scoring hospitals in a single system has not happened before to my knowledge.\u00a0 At least two hospitals elsewhere in Kentucky currently working under federal compliance oversight to settle charges of fraudulent billing and quality issues got much better scores than these.<\/p>\n
\nAre any differences in patients served large enough to explain these low scores? \u00a0Is all quality local, such that large chain hospitals are insufficiently nimble to deal with local situations? Certainly CHI hospitals in some other states like Nebraska did very well with Leapfrog, but Nebraska hospitals did well overall.\u00a0 Other CHI hospitals such as in Texas are in the same ballpark as Kentucky. \u00a0Is it possible that the layoffs and financial difficulties of KentuckyOne and CHI have begun to effect clinical care? \u00a0Is the rating system itself worthless? \u00a0If it is that bad it needs to be thrown out altogether. Don\u2019t you think it is important to know?\u00a0 Because Leapfrog’s quality and safety factors largely track those of Medicare, it is likely that Medicare payments to these hospitals will be cut further.\u00a0 Is that the way to improve the quality of medical care?\u00a0 I wish I knew the answers to these questions.<\/p>\n
\nNote that only 52 of Kentucky’s hospitals were rated.\u00a0 The many small Medicare Critical Access Hospitals that primarily serve rural areas are not required to report their quality measures!\u00a0 Go figure.\u00a0 They still receive their cost plus a profit like in the good old days. I am unaware that their Medicare payments are subject to any of the “incentives” that the rest of the Kentucky’s hospitals are.\u00a0 If I were a hospital that had to commit the hugely expensive and manpower-devouring resources to all the reports that regular hospitals are required to submit, I would be unhappy.\u00a0 Is the effort worth it or not?\u00a0 Which hospitals should be excused or protected?\u00a0 Are we on a slippery slope to dismantling the entire quality-evaluating system?<\/p>\n
\nFor all my skepticism, it is difficult for me to dismiss the significance of the low scores. \u00a0A number of Leapfrog cycles back, University Hospital received a ‘B’. \u00a0What happened since? \u00a0I would like to be uncritical or at least neutral, but I have been made aware of increasing reports of major dissatisfaction from senior clinical faculty over the management of University Hospital. \u00a0Insufficient and inexperienced staffing and lack of understanding of the needs of a tertiary teaching hospital lead the list of complaints. \u00a0I have been told by several of my colleagues that University Hospital has not been receiving the share of funding it expected from the joint management agreements and that declining funding is impacting the hospital adversely. \u00a0Faculty are\u00a0talking openly about\u00a0the feasibility of unwinding the agreements with KentuckyOne.\u00a0 My readers are aware that I have always thought that the partnership was a bad idea.<\/p>\n
\nThere is little doubt that money is tight if not vanishing at the Hospital. Clinical income should be and was going up because of Kentucky’s healthcare reform\u2013 but is the money staying in the hospital? \u00a0Is money still being drained off for non-clinical uses such as research and general University activities? \u00a0Is University Hospital revenue being used to pay the debt of CHI or to prop up other KentuckyOne hospitals? \u00a0The University of Louisville Foundation collects and manages the funds of\u00a0a number of endowed programs within and without the University.\u00a0 I am reliably told that because of the poor performance of its investments, that the Foundation has told endowed program leadership that their budgets will be unexpectedly and substantially cut from hundreds of thousands to a million dollars each\u2013 including the Cancer Center. \u00a0This is occurring against a\u00a0background of fabulous executive salaries, “loans<\/a>” of millions of dollars by the University to the Foundation, expensive<\/a> ill-conceived legal battles, attempts to raise already unaffordable student tuition, and full-page ads extoling the virtues of President James Ramsey which are ironically silent about what he has wrought at the Medical Center. \u00a0I am advised that these cuts from the Foundation will damage the Hospital’s academic programs.\u00a0 How can it not hurt its clinical programs as well?\u00a0 This is a time when resources should be flowing into University Hospital, and not drained away to support other institutions or initiatives\u2013 or anything else except providing clinical care and medical education. Who will reassure us that this is happening? \u00a0University Hospital should certainly not be used today as a slush\u00a0fund to finance research, high executive salaries, or somebody else’s debt. University Trustees who are asked\u00a0by President Ramsey to raise tuition<\/a> should be freed from their bondage and allowed to ask what is really going on at the University of Louisville. The principle aspiration of a teaching hospital and Medical School should be to provide the very best medical care in the city. \u00a0Get that right first. \u00a0We do not seem to be there yet.<\/p>\n
\nEmeritus Professor of Medicine, UofL
\n7 June 2016<\/p>\nShare this:<\/h3>