JustCare

Tag: Ratings

  • Hospital rating systems are all flawed

    Hospital rating systems are all flawed

    You should choose your hospital carefully, but do not rely on a hospital rating system. A new paper in the New England Journal of Medicine finds that all hospital rating systems are flawed. While the researchers did not give any hospital rating system an F, they did not give any an A grade either.

    Most noteworthy, the researchers gave the Centers for Medicare and Medicaid Services’ (CMS) Hospital Star Ratings a C grade, meaning it is a “mediocre rating system” with a “fair bit of misclassification.” This comes as no surprise given that the HHS Office of Inspector General has recommended that CMS do a better job of data auditing to ensure hospitals are not inappropriately manipulating data or inaccurately reporting data.

    The researchers gave U.S. News & World Report a B grade, which was the highest grade. Leapfrog and Healthgrades received the lowest grades, C- and D+, respectively.

    The researchers found that every hospital rating system had shortcomings that could mean misreporting of performance. In some cases, quality measures were flawed. In other cases, data was not validated or methodologies were poor, without meaningful peer review.

    The researchers also pointed out that hospital ratings systems do not offer a good holistic evaluation. They explained that it is confusing at best to read that a hospital performs well on one measure and poorly on another. What is a person to do with this conflicting information?

    Of note, the researchers reported that most of the hospital data reported comes from the traditional Medicare program, a serious shortcoming, reflecting care provided to only one subpopulation. They recommended that data come from an all-payer database to better reflect hospital quality of care for all populations.

    How should you choose a hospital? It’s not easy to know which ones deliver the best care. You should probably avoid hospitals with low ratings. You should also try to avoid ones that Medicare fines because of high readmission rates, high infection rates or high numbers of patient injuries. You can look those hospitals up here. Your best bet may be to talk to your doctors about the hospitals in your community they recommend.

    Here’s more from Just Care:

  • How do you choose a hospital?

    How do you choose a hospital?

    All hospitals are not created equal. In fact, there are some with records suggesting you may leave in worse health than you arrived. Many factors contribute to whether a hospital will provide you with the care you need and not jeopardize your health. So, how do you choose a hospital?

    CMS updated its Overall Hospital Quality Star Ratings in February. It gave only 293 hospitals out of more than 4,500 a five-star rating.

    CMS’ Hospital Compare website reports on quality measures that go into its star ratings. Medicare has been collecting data on hospitals and rating them on Hospital Compare for several years, based on 62 independent ratings.

    On Hospital Compare, you can learn about hospitals with high readmission rates and hospitals that CMS has penalized, hospitals which you might want to avoid. You can also learn about hospitals with high rates of hospital-acquired infections.

    Questions that are factored into the star-rating system include:

    • How frequently do patients get an infection after surgery?
    • The average wait patients have in the Emergency Department before seeing a doctor?
    • How often do patients develop complications after hip replacement surgery?
    • Chances of patients being readmitted to the hospital after a heart attack?
    • The number of times patients receive CT scans or MRI’s?

    Medicare star ratings do not tell the whole story about the quality of a hospital, and you should not rely exclusively upon them.

    If you are choosing a hospital, you should also visit the Informed Patient Institute, a non-profit that grades the different entities rating hospitals in each state. Right now, the IPI gives Medicare’s Hospital Compare a B grade because there is a lot of missing data. Medicare has not collected information on several measures.

    Here’s more from Just Care:

  • Medicare ratings of Medicare Advantage plans a farce

    Medicare ratings of Medicare Advantage plans a farce

    Back in January 2016, the Centers for Medicare and Medicaid Services sanctioned Cigna for threatening the health and safety of its members in Medicare Advantage plans. But, notwithstanding Cigna’s sanction and “its longstanding history of noncompliance with CMS requirements,” a new CMS policy allows Cigna to retain its multi-star ratings, making Medicare ratings of Medicare Advantage plans a farce.

    The sanctions against Cigna precluded Cigna from enrolling new Medicare Advantage members or marketing its plans to prospective members. According to CMS, “Cigna’s conduct poses a serious threat to the health and safety of Medicare beneficiaries.” But, the new CMS policy means that Cigna is still eligible to receive hundreds of millions of dollars in financial rewards from Medicare.

    And, because the new policy allows Cigna to keep its multi-star ratings, the star ratings also mislead people who are looking at Medicare’s star ratings as they consider whether to join a Medicare Advantage plan. Medicare star ratings are supposed to indicate a health plan’s performance, including the quality of its care. But, CMS reports that Cigna has delayed and denied its members access to medical services and prescription drugs as well as increased their members’ out-of-pocket costs for care in violation of CMS requirements.

    Earlier this month, MedPAC, the independent commission that oversees Medicare, found that the Medicare Advantage star ratings do not help people with Medicare for yet another reason. They do not allow you to compare individual Medicare Advantage plans in a given community. CMS grants health plans stars at “the contract level,” meaning that they are granted to an insurance company for a bunch of their Medicare Advantage plans, not to individual plans. Consequently, a Medicare Advantage plan that performs poorly can still get a five-star rating if an insurer packages it with better performing plans.

    Think carefully, when choosing a Medicare health plan and follow these tips:

  • Don’t be misled by “five-star” nursing home ratings

    Don’t be misled by “five-star” nursing home ratings

    In the fall of 2014, The New York Times reported that Medicare five-star nursing home ratings do not ensure quality because key data is self-reported.   A new follow-up investigation by Kaiser Health News now confirms that most nursing homes have inadequate staff and have been misrepresenting their staffing levels to Medicare.
    In short, much of the information you can find on MedicareCompare about nursing homes is based on self-reported data. Since nursing homes have been misrepresenting their staffing levels to Medicare, the star-ratings Medicare confers based on this data should not be trusted.

    Independent assessors are supposed to conduct health inspections each year.  So those results should be reliable.  But, staff levels and quality data are self-reported.

    Unfortunately, reliable information that compares the 15,000 nursing homes in America is not yet available. For now, there’s no TripAdvisor or Consumer Reports to give you the full scoop. Still, it’s important to keep in mind that quality differs significantly and to do your homework before choosing a nursing home.

    Informed Patient Institute offers the best information on nursing homes and other providers in each state.  It is likely too generous in giving MedicareCompare a B grade, without listing all its shortcomings.  But, where they exist, it tells you about better tools available to you and is worth checking out.

    Talk to people in your community about nursing home options. If possible, avoid chain nursing homes. And, check out small nursing homes, Green Houses. Visit the nursing homes a few times before choosing one.  Find out about consumer complaints and whether there have been fines imposed on the nursing home by state agencies.

    Here’s more from Just Care:

  • Beware of chain nursing homes

    Beware of chain nursing homes

    A Kaiser Health News analysis finds that nursing homes that outsource their services to “related organizations”–chain nursing homes that get their goods and services from companies their owners control–may pose serious risks to residents. If you are choosing a nursing home, be sure to check federal inspection, staffing, and quality records. And, make a point of looking at independent nursing homes, which generally offer far better conditions for their residents than chain nursing homes.

    Keep in mind that nursing home chains that outsource to related organizations are likely to have higher ratios of patients to nurses and aides and more patient injuries and unsafe situations than independent nursing homes. Twice as many people complain about these conglomerates as they do about independent nursing homes. These nursing home chains spend much less money on patient care than their independent counterparts.

    Jordan Rau writes in the New York Times about residents of these chain nursing homes who are left unattended and develop gangrene, go unwashed, and are left to sleep on urine-soaked sheets. The nursing homes generally do not have adequate staffing.

    Chain nursing homes are the norm. More than 11,000 nursing homes–about three out of four of them–are part of a chain. In a large number of instances, a big chunk of their revenue goes to their owners, and little is left for staffing and other resident needs. Rau reports that rather than deliver appropriate care to its residents, Allenbrooke Nursing and Rehabilitation Center distributed 28 percent of its nursing home revenue to its two owners over eight years, $40 million of its $145 million in revenue.

    Medicare provides star-ratings to nursing homes. But, five-star rated nursing homes do not mean they offer quality care. A lot of the data that Medicare collects on staffing levels and quality of care is self-reported. The Insured Patient Institute offers good independent information on the web sites that rate nursing homes in your community.

    Here’s more from Just Care:

  • New online information sources to help you choose a doctor

    New online information sources to help you choose a doctor

    How do you find a doctor that’s right for you?  Most people still rely primarily on the advice of family and friends, and the recommendations of other doctors. But there are increasingly good sources of information online these days, including consumer reviews, ratings and databases that show doctors’ ties to drug and device companies.

    In late March, Consumer Reports released a new resource–ratings of primary care group practices in six states and two metro areas.  Even if you don’t live in one of the eight states where Consumer Reports has rated doctors (California, Massachusetts, Maine, Michigan, Minnesota, Ohio, Washington and Wisconsin), you might want to check out how they did it and the advice they give on finding a good doctor.

    In addition, the cover story of the May issue of Consumer Reports magazine is entitled “What You Don’t Know About Your Doctor Could Hurt You.” It probes the failure of government and the medical profession to stop bad or troubled doctors from practicing medicine, even after they’ve been caught.

    Consumer Reports is just the latest media outlet to release physician ratings.  The online media organization ProPublica, for example, used Medicare data to rate some 16,000 surgeons nationwide in 2015, with a focus on complications after surgery, as I reported on Just Care back in July 2015.

    ProPublica also provides a searchable database of doctors who have received payments and gifts from drug and medical device companies. A recent analysis by the group provides strong evidence that docs who take payments prescribe more expensive brand name drugs than docs who don’t take the payments.

    The Affordable Care Act mandated creation of the database, and drug and device companies are required to divulge the payments.

    Another recent web launch, Amino.com, says it can match you up with doctors in your area who have treated the largest number of patients like you—same condition, gender, and age range.  Like ProPublica, Amino relies on Medicare data that it says encompasses 890,000 doctors and other providers, four billion insurance claims, and 188 million people. It’s still early days for this site, but over time, it could be a valuable service.

    What about web sites that allow consumers to rate their doctors?   A 2012 study found that one in four Americans had consulted such a site.  They can provide a slice of useful information, but buyer beware: many doctors listed on such sites have been rated by fewer than 10 patients.  That’s not enough to generate a meaningful, statistically valid rating, experts say.  Thirty consumer reviews is a minimum.  In addition, there’s still concern that the sites can be gamed by doctors, although there’s no proof that’s widespread. In sum, you might want to check out these reviews, but you should not rely on them to pick your doctor at this point in time. 

    For those interested in exploring this topic in greater depth, the April issue of the journal Health Affairs has a batch of relevant articles.   You’ll see my article on provider ratings.

    Enhanced scrutiny of physician quality of care and treatment results—and the reporting of that to consumers—has been building slowly for years.  It’s poised to accelerate in 2016 and beyond.  And that’s a good thing for consumers.

    Here’s more from Just Care on choosing a doctor:

  • Should you care whether a hospital employs its doctors?

    Should you care whether a hospital employs its doctors?

    A recent Kaiser Health News article notes that doctors who once practiced on their own are increasingly working for hospitals. The idea, at its best, is that doctors who practice in a group setting, like a hospital, can better coordinate care and improve quality of services for patients. At its worst, the hospital sees the doctors as a means to generate more revenue. Should you care whether a hospital employs its doctors?

    In September, Broward Health, a non-profit hospital system based in Florida that employs its doctors, paid $70 million to settle charges that it was improperly kicking back money to doctors for making patient referrals to the hospital. For decades, policymakers have tried to prevent such arrangements on the theory that they can encourage doctors to deliver more care than necessary, driving up costs and potentially harming patients.

    The question remains whether promoting good care has anything to do with how doctors are paid? Or, is it about the goals of the people directing and providing care. Broward’s goals appear to have been revenue-based. But, not all hospitals who hire their doctors share those goals.

    The Veterans Administration (VA) doctors are employees. Based on many studies comparing patient safety and health care quality under different payment systems, the VA offers “the best care anywhere.”  The VA has been lauded for giving systematic attention to appropriate treatment in ways other hospitals do not. It encourages a team-based coordinated care approach to care.

    That said, not only is there huge quality and safety variations among hospitals, but there can be large variations within a hospital or a hospital system. The Wall Street Journal reports that patient care varies widely at VA hospitals.

    So, how is a person to choose among health care providers? For good reason, the public is not focused on health plan quality.  And the various hospital ratings will at best tell you a piece of the hospital quality story. A lot of data is still not available. But, make sure you look at hospital infection rates.  Moreover, keep in mind that the quality of care delivered turns in significant part on the doctors who are providing care. For more information about the different provider ratings available through Medicare and elsewhere, visit the Informed Patient Institute.

  • Are hospitals driving up costs for people with Medicare to improve quality ratings?

    Are hospitals driving up costs for people with Medicare to improve quality ratings?

    In a new Health Affairs post, David Himmelstein and Steffie Woolhandler argue that Medicare’s pay-for-performance system might be doing more harm than good, when it comes to hospital readmissions. Hospital readmission rates are not dropping as much as the data might suggest. Rather, they say that while some hospitals have redesigned their systems to improve patient care pre-discharge so that patients do not need to be readmitted soon after, other hospitals have been gaming the system to make it appear so.

    Medicare’s new payment incentive system financially penalizes hospitals with high readmission rates. To meet quality standards imposed by the Centers for Medicare and Medicaid services, some hospitals have been reclassifying patient visits within 30 days after discharge so they do not count as readmissions. They either classify patients as outpatients, on “observational” status, or they admit these patients to the emergency room.

    As a result, hospital quality improvement is likely not as significant as the Medicare readmission data would suggest. What’s worse, hospitals that fail to “readmit” patients who have been discharged within 30 days may be penalizing those patients financially. Even if they remain on observational status for several days, they will be ineligible for Medicare skilled nursing or rehab services. (To qualify for Medicare skilled nursing or rehab coverage, patients must be admitted to hospital as inpatients for at least three days in the 30 days prior to getting that care.) And, their out-of-pocket costs could be significantly higher while in hospital.

    To support their claims, Himmelstein and Woolhandler reveal that hospital outpatient stays increased 96 percent in the seven years between 2006 and 2013. The rise in outpatient stays represents more than half of the decline in reported hospital readmission rates. There has also been a notable increase in hospital emergency department visits.

    Hospital charges are already sky high in most areas of the country. And, competition is not reining them in. Some purchasers are using reference pricing to bring them down.  Health economist Uwe Reinhardt makes the case for an all-payer payment system.

  • How safe are outpatient surgery centers?

    How safe are outpatient surgery centers?

    Medicare now covers surgeries in some 5,500 outpatient surgical centers. Patients often like receiving care from these surgical centers because they say they are often more convenient than hospitals, they don’t have to wait as long for treatment and they get more personalized care. And, according to Consumer Reports, about 54 million surgeries are performed each year at these facilities. The question remains are they as safe as hospitals?

    Lisa McGiffert, who runs the Safe Patient Project at Consumer Reports questions their safety. Outpatient surgery centers like hospitals are breeding grounds for bacteria that can cause serious infections if the facilities are not kept clean. But, these centers tend not to be as tightly regulated or monitored to the same degree as hospitals. So, it’s not possible to know as much about what’s going on inside them.

    In addition, these centers may not have the safety equipment available at a hospital in case of an emergency such as a defibrillator and other lifesaving equipment. Moreover, they may not have staff with the level of training and skills to handle an emergency that are on hand in hospitals.

    Before getting care at an outpatient surgery center, do some research. Try to learn about the center’s infection rates. Make sure that the center is accredited, that your surgeon has experience with the procedure you are getting and that your anesthesiologist is board-certified.

    Right now, it may be hard to find good data on outpatient surgery centers. We should expect it over time. If you have a serious health condition, you may be better off getting your surgery in a hospital, because they are better equipped to address complications. (You should also choose your doctors carefully.)

    We are beginning to see more data rating hospitals, surgeons and doctors on a number of different metrics, including patient safety data from Consumer Reports.

    If you get treated in an ambulatory surgical center, be sure you understand what will happen after you leave. Leaving has its own set of risks if you are not prepared.

    The Agency for Healthcare Research and Quality is currently funding a 12-month patient safety program in which outpatient surgical centers can participate. And in 2014, Medicare began asking these centers for reports on quality, providing payment increases for those centers that comply.

  • Medicare begins rating home health agencies

    Medicare begins rating home health agencies

    Much like surgeons, home health agencies are not created equal. To help people better compare Medicare-certified home health agencies, Medicare just launched Home Health Compare. It’s a web site that helps you see some quality differences among home health agencies in your community rates.

    There are a lot of factors that go into whether a home health agency is good, bad or great. So, you should talk to your doctor and other people you know and trust about home health agencies in your area as well as look at Home Health Compare. The Informed Patient Institute provides good information about health care quality, patient safety and health care costs as well as the usefulness of report cards.

    Right now, Medicare is rating agencies for the quality of their patient care based on nine of 27 process and outcomes measures.

    • Process measures include how quickly the patient received needed care, whether the patient got a needed flu shot and whether the agency educated the patient about his or her medications.
    • Outcomes measures include whether the patient got better at walking, bathing, and getting into and out of bed, as well as whether the patient experienced less pain and shortness of breath.

    Some home health agencies may not offer the full range of Medicare-covered services you need. On Home Health Compare, you can find out which services different agencies provide, including nursing care, physical therapy, speech therapy, occupational therapy, social services, home health aide services.