The Dicey Connection between Hospital Ratings and Superior Patient Care

 

Dear Readers,

When patients check in to San Francisco General Hospital, they’re met by a “chief patient experience officer” whose job is to treat them with respect and personalized attention instead of the assembly line all too common in U.S. health care.

Call me cynical, but this might just connect to a federal effort to compensate hospitals at least partly on the basis of surveys of inpatient experiences that include quality-of-life issues as well as medical concerns and treatment. The happier the patients, the thinking goes, the better the hospital’s bottom line.

It’s hardly a straight line between patient satisfaction and hospital success, much less superior care. This month we look at why it’s so difficult to assess hospital performance, and the standards by which it should be judged.

Everyone Has an Agenda

We’ve written in our patient safety blog about the questionable nature of hospital rankings such as the ones done by U.S. News & World Report, whose latest “Best Hospitals” list was released last month.

Ratings always reflect some kind of bias. Some hospitals are ranked higher because of their reputation within medical community, which often has nothing to do with patient satisfaction, or maybe even safety. Some are higher in social media rankings because the food’s good and all patients get private rooms. But such measures might ignore important considerations like infection control, and the ability of staff to manage the transition home to prevent readmissions. (See our newsletter, “You Can Go Home Again.”)

Sometimes, patients might have an ax to grind because of a personal experience that, although it’s important to them, isn’t necessarily characteristic of the hospital’s overall quality of care. But those feelings will get the same weight on Yelp as more objective responses.

The government’s Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) includes questions such as “After you pressed the call button, how often did you get help as soon as you wanted it?” “Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?” Administered to a random sample of patients continuously throughout the year, it has 32 questions that encompass critical aspects of the hospital experience. Read about it here.

How Executive Pay Skews Some Rankings

A confounding factor of assessing hospital performance and what’s important to you is how executives are compensated. A blockbuster story in June by Kaiser Health News and ABC described the twisted nature of health-care financing and why health care costs the U.S. economy far more than that of other developed countries, provides lesser outcomes and has an unsustainable growth rate.

Simply put, hospital executives often are compensated much more for boosting volume than for delivering value. Getting paid for big numbers rather than impressive quality, say economists and policy experts, undermines measures that aim to cut unnecessary treatment and control costs.

“Boards of trustees in health care are oriented around top-line, revenue goals,” Dr. Donald Berwick, former head of Medicare and Medicaid, told KHN/ABC. “They celebrate the CEO when the hospital is full instead of rewarding business models that improve patients’ care.”

When 30% of U.S. health care is unnecessary, as the Institute of Medicine estimated, when U.S. hospitals spend twice as much per discharged hospital patient as other developed nations without delivering much better results, according to the Commonwealth Fund, you have to ask why.

Here’s the answer KHN/ABC found: “Hospital CEOs are paid to make it that way.”

Valley Medical Center in Seattle gets a cut of local property taxes. Like other hospitals across the country, it regularly adds space, programs, amenities and technology once reserved for top teaching hospitals, even though it has a modest 300 beds.

As a result of its new surgery center, birthing center with whirlpool tubs and a lobby featuring pyramid skylights and waterfalls, among other development, patient revenue doubled over the decade ending in 2012.

Pretty much every time there was ribbon-cutting ceremony, CEO Richard Roodman got a bonus. In 2012 his pay was $1.2 million, including a $213,000 bonus, about one-third of which was related to financial goals and expansion. Each time Valley exceeded profit goals for three consecutive years, Roodman earned a bonus. When patient volume increased in 2009, he got a bonus. When urgent-care center visits grew the same year, he got another bonus.

Much of U.S. health care waste and inefficiency is a result of the “pay per procedure” model that gives physicians incentives to perform excessive treatment. But, as KHN/ABC point out, “[F]ew seem to have noticed that incentives for the bosses like Roodman who run the hospitals and supervise the doctors point in the same direction.Because hospital officials feel obligated to put expensive equipment to use, many analysts believe the mere existence of new programs increases treatment and spending whether they are needed or not.”

That’s a difficult thing to see in a rating or patient survey, but it certainly affects the quality of care in the long term-overuse is not efficient, it invites medical complications and it’s expensive.

We’ve written often about this almost Pavlovian response to more and newer medical stuff. Valley is a good example of this. In 2011, according to KHN/ABC, “its board offered Roodman a reward if the hospital increased the number of angioplasties, a procedure to clear coronary arteries that many experts believe is overprescribed. The hospital missed that target but achieved another goal on the CEO bonus menu: increasing surgeries using its da Vinci robot, a system questioned for costing much more than other methods without adding any proven benefits.

Learn More From a Variety of Resources

There are several ways to assess U.S. hospitals in terms of safety and patient satisfaction. We’ve written about  Medicare’s Hospital Compare site, the Leapfrog Group, which focuses on informing people about hospital safety and quality, and Planetree, a nonprofit organization that promotes patient-centered care in hospital design and management.

The Dartmouth Atlas Project documents variations in how medical resources are distributed in the U.S. using Medicare data to provide information and analysis about hospitals and their affiliated physicians. You can search by hospital, region and topic.

Consumer Reports is known for rating all kinds of consumer goods, from cars to cameras. Consumer Reports Health now rates more than 4,000 hospitals on 12 criteria including cleanliness, staff communication, pain control and infection rates, although access to the site requires subscribing.

Consumer Reports also has a new hospital surgical rating based on the percentage of Medicare patients undergoing surgery who die in the hospital or stay longer than expected. It examined 27 kinds of scheduled surgeries, and developed specific ratings for five of them: back surgery, replacements of the hip or knee, and procedures to remove blockages in arteries in the heart (angioplasty) or neck (carotid artery surgery). See how individual hospitals rated here.

You can review the accountability measures offered by the Joint Commission, an independent, nonprofit organization that accredits and certifies more than 19,000 health-care organizations and programs in the U.S.

See our newsletter from a couple of years ago about the “volume” rule-that a hospital that regularly treats lots of patients with your medical issue has worked out sets of standard practices to ensure the safest, best experience for you.

It’s interesting to note that Valley Medical Center’s quality scores as compiled by Hospital Compare and the Washington Hospital Association, for example, were similar to others in its area. It got a “B” in safety ratings from Leapfrog, but was one of the most-penalized hospitals in the state for its high rate of readmissions for Medicare patients.

“Boards tend to be comfortable with kind of average performance [in quality],” Berwick told KHN/ABC. “Whereas they might demand very aggressive performance in terms of volume and expansion, they tend to fall silent when the report shows average levels of care.”

So average might not pass muster for you. To find out what does, remember that a single resource or ranking is unlikely to offer sufficient perspective to weigh a facility’s relative merits. Determine your priorities, review several sources of information and ask questions of a hospital’s patient advocate.

 

Here’s to a healthy 2013!

Sincerely,
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Patrick Malone
Patrick Malone & Associates