Many five-star hospitals scored low on other measures

A large percentage of hospitals that received Medicare's top five-star rating on patient satisfaction were penalized for excessive readmissions or fared poorly on curbing hospital-acquired conditions, a Modern Healthcare analysis shows.

Of 151 five-star hospitals on which data were also available for three other CMS quality programs, 39% received a penalty for excessive 30-day readmissions. In addition, 47% received a score of 5 or higher for hospital-acquired conditions (HAC) on a 1-10 scale where 1 is the best. The remaining 100 five-star hospitals did not have fiscal 2015 data reported for the other CMS quality programs.

Most of the 151 hospitals did well on value-based purchasing, which rewards or penalizes facilities based on how they perform on a suite of quality measures, including patient satisfaction. But many experts say those measures do not necessarily reflect the outcomes patients care most about, including mortality and readmission rates.

The CMS posted the star ratings April 16 on its Hospital Compare website, based on a five-star scale with 5 being the highest score. The ratings reflect an average of hospitals' performance on 11 measures from the Hospital Consumer Assessment of Healthcare Providers and Systems survey. That survey includes patient evaluations of the hospital staff's responsiveness, care transitions, how well information about medications is communicated, and cleanliness and quietness of the facility. The ratings are from patient responses gathered between July 1, 2013, and June 30, 2014.

The agency cautioned that patient experience captures only one aspect of hospital quality and that patients should consider multiple factors when choosing a hospital.

But some experts reacted skeptically to the CMS' star-rating effort. And a new report from the Institute of Medicine said many of the measures healthcare providers are required to report are redundant, fragmented and limited in value.

High performance on a single quality measure does not always mean high performance on others, said Dr. Robert Wachter, a quality and safety expert at the University of California San Francisco. Still, when staff members are well-trained and have a data-based quality-improvement effort in place, and the organization is focused on the best possible patient experience, a hospital that does well on one measure will do well on all the others, he said.

Here are two examples of five-star hospitals that did not do well on other federal quality measures.

In fiscal 2015, the Doctors Hospital at Deer Creek in Leesville, La., was dinged with a -1.1% value-based purchasing penalty and a -2.4% readmissions penalty, and it received a middling HAC score of 5. The hospital did not respond to a request for comment.

HAC scores are based 35% on patient-safety indicators, including rates of pressure sores, sepsis and accidental punctures. The remaining 65% is based on central-line blood stream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates.

The Heart Hospital Baylor Plano, a specialized vascular facility in Texas, received a 10 for hospital-acquired conditions in fiscal 2015. Its chief nursing officer, Susan Moats, attributed the poor score to government scoring methodology that does not take into account its care model of admitting patients directly to a patient room rather than admitting them through the intensive-care unit. “They don't know how to interpret our data, so they don't count it,” she said.

The CMS has proposed a fiscal 2016 rule change that would allow it to code for hospital beds outside the ICU, expanding the population covered by the CLABSI and CAUTI measures of the HAC program.

Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, said she was surprised to see a disproportionate number of five-star hospitals in certain states. Out of all 251 five-star hospitals, there were 31 in Texas, 25 in Wisconsin and 17 in Louisiana. “The public deserves to know if this is an accurate reflection of differences in care experience or if there is some other factor,” she said.

Dr. David Blumenthal of the Commonwealth Fund and Dr. Michael McGinnis of the Institute of Medicine wrote in an April 28 JAMA editorial that “not only are many measures imperfect, but they are proliferating at an astonishing rate, increasing the burden and blurring the ability to focus on issues most important to better health and healthcare.”

Moats agreed. “Even as a chief nursing officer with an advanced degree, it can be challenging to absorb and understand the metrics. We are on the precipice of helping consumers make informed choices, but I think it's important to question data,” she said.