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Daily Archives: April 20, 2016

Medicare Delays Plans For New Star Ratings On Hospitals After Congressional Pressure

Bowing to pressure from the hospital industry and Congress, the Obama administration on Wednesday delayed releasing its new hospital quality rating measure just a day before its planned launch.

The new “overall hospital quality” star rating aimed to combine the government’s disparate efforts to measure hospital care into one easy-to-grasp metric. The Centers for Medicare & Medicaid Services now publishes more than 100 measures of aspects of hospital care, but many of these measures are technical and confusing since hospitals often do well on some and poorly on others. The new star rating boils 62 of the measures down into a unified rating of one to five stars, with five being the best.

But this month, 60 senators and 225 members of the House of Representatives signed letters urging CMS to delay releasing the star ratings. “We have heard from hospitals in our districts that they do not have the necessary data to replicate or evaluate CMS’s work to ensure that the methodology is accurate or fair,” the letter from the House members said.

In a notice sent Wednesday morning, CMS told Congress it would delay release of the star ratings on its Hospital Compare website until July. “CMS is committed to working with hospitals and associations to provide further guidance about star ratings,” the notice said. “After the star ratings go live in their first iteration, we will refine and improve the site as we work together and gain experience.”

Mortality, readmissions, patient experience and safety of care metrics each accounted for 22 percent of the star rating, while measures of effectiveness of care, timeliness of care and efficient use of medical imaging made up 12 percent in total.

The hospital industry for months has been urging this delay, arguing that many of the measures will not be relevant to patients seeking a specific service. For instance, a hospital’s death rate for Medicare patients might be irrelevant for a woman trying to decide where to give birth.

The industry’s major trade groups said in a letter to CMS that some hospitals perform poorly because their patients tend to be lower income and don’t have the support at home. Many of the nation’s most prestigious hospitals have been bracing for middling or poor ratings.

Last year, CMS created a star rating to represent the views of patients in surveys. Two sets of researchers recently determined that hospitals with more stars in patient experience tended to have lower death and readmission rates.

Hospital Compare received 3.7 million unique page views last year, according to a paper published this month in the journal Health Affairs. The author, analyst Steve Findlay called the traffic “not at a level commensurate with [the] stature and potential” of the federal government’s health care facility comparison sites.

Dr. Ashish Jha, a Harvard School of Public Health researcher, said consumers will be more likely to use the unified star ratings, but this approach raises concerns. “What I worry about with the new star rating that’s coming out is that we will be mixing in a lot of noise with things that absolutely are important for patient, he said. “The idea that dying and being readmitted to the hospital are equally important to patients seems funny to me.”

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At Teaching Hospitals, Aggressive Screening May Lead To Medicare Penalties

CHICAGO — The puffiness along Carol Ascher’s left leg seemed like normal swelling, probably from the high dose of chemotherapy Dr. Karl Bilimoria had injected the previous day. But it could have been a blood clot. He quickly ordered an ultrasound.

“We were just being abundantly cautious,” he said.

Such vigilance is a point of pride at Northwestern Memorial Hospital. But the hospital’s tests have identified so many infections and serious blood clots that the federal government is cutting the institution’s Medicare payments for a year, by about $1.6 million.

Nearly half of the nation’s academic medical centers are being punished similarly through one of the federal government’s sternest attempts to promote patient safety. Medicare is reducing a year’s worth of payments to 758 hospitals, including some of the most prestigious teaching hospitals in the country, with the highest rates of infections and other potentially avoidable complications, including blood clots after surgery, bed sores, hip fractures and sepsis.

The penalties, created by the federal Affordable Care Act, have incited a vehement debate about quality at many academic medical centers often revered for cutting-edge treatments and top specialists. Are these vaunted hospitals really more dangerous than local, unsung hospitals?

This KHN story also ran in The New York Times. It can be republished for free (details). logo NYTimes

Or, as Northwestern and some other academic medical centers argue, are these hospitals being perversely penalized because they are so aggressive in screening patients for problems? At Northwestern, the penchant for ordering lab tests is so prevalent that physicians often refer to a “culture of culturing” that they credit for helping to keep the death rate there lower than at most hospitals.

“If you don’t look for infections, you’re never going to find them,” said Dr. Gary Noskin, Northwestern’s chief medical officer.

Since 2008, Medicare has refused to reimburse hospitals for treating complications they created, but studies have found that the change has not resulted in substantial decreases in harm. Nationwide, infections and other avoidable hospital complications remain a threat to patients, occurring during 12 of every 100 stays, according to a federal estimate. Patients were hurt in some way more than four million times when hospitalized in 2014.

Hurting Hospitals With Sickest Patients?

The new Medicare penalties, which reduce payments by 1 percent for a year, were begun in October 2014. Last December, Medicare announced its second round of penalized facilities, which include Stanford Hospital in California, the Cleveland Clinic, and Brigham and Women’s Hospital in Boston, which trains residents from Harvard Medical School. Intermountain Medical Center in Utah and Geisinger Medical Center in Pennsylvania, both of which President Obama has singled out for excellence, also are being penalized.

The average penalty is estimated at about $480,000, but most academic centers will lose more since they have higher revenues. Medicare says the punishments are effective and notes that teaching hospitals as a group are improving more rapidly than other hospitals.

Dr. Kate Goodrich, Medicare’s quality director, said in a statement that the “scores and penalties show an improvement among large teaching hospitals” since the first year of the fines. In some areas, including catheter-associated infections, the rate of injuries at teaching hospitals decreased faster than at other hospitals, she said.

“It’s not only the magnitude of the penalty, but the publicity that comes out of being penalized,” said Dr. Kevin Kavanagh, a patient safety advocate from Kentucky.

Even hospitals that are improving can be disciplined because Congress required Medicare to fine a quarter of hospitals each year (excluding some special categories such as those serving veterans). Most teaching hospitals penalized this time, including Northwestern, were also fined the previous year.

Dr. Atul Grover, chief public policy officer at the Association of American Medical Colleges, said the fines hurt hospitals, such as academic centers, that have the sickest patients. Medicare is “punishing hospitals for taking on cases that nobody else wants,” he said.

If you don’t look for infections, you’re never going to find them.

Dr. Gary Noskin

The Centers for Disease Control and Prevention has been collecting infection reports from hospitals for decades to help experts identify problems and measure progress in combating dangerous germs. Kristen Metzger, an infection prevention specialist at Northwestern, said that since Medicare now uses the CDC reports in determining penalties, physicians sometimes get into disputes with her team about whether a case meets the criteria to be reported.

“Every week at our meetings it almost always turns into an argument” about what Northwestern is calling an infection, and whether the hospital is being too strict, Metzger said.

Question About Reporting

Federal officials are concerned that not all facilities may be diligently reporting infections. In October, the government informed hospitals that it had heard that some employees were discouraging tests that might identify one of the infections the CDC tracks. The government also said it had been told that in some places, employees unnecessarily tested patients upon admission to document infections they arrived with. While saying there was no evidence of widespread fraud, the government invited whistle-blowers to report misconduct.

Northwestern identifies an unusually high rate of infections around the sites of colon surgeries, about one in every 19 operations, according Medicare’s most recent public data. Its rates of blood clots after surgeries are also high. The hospital reports one urinary tract infection for every 260 days that patients in the intensive care unit had catheters in place — a rate that is still higher than at most hospitals even after taking into consideration the fact that teaching hospitals tend to have patients with more infections.

Medicare is scheduled to release updated infection rates later this month and the next year of penalties will begin in October.

The most reliable way to reduce urinary infections is to avoid using catheters or to take them out as soon as possible, infection experts say. Hospitals such as Brigham and Women’s, which says it loses about $2.6 million each year it is penalized, have given nurses authority to remove urinary catheters in specific situations without getting physician approval to limit their usage. Rob Bailey, a Northwestern nurse, said that was not possible for particularly ill patients.

One of his patients, comatose and obese, arrived with bed sores that would have been aggravated by movement. “I don’t think there’s anything we could have done differently,” Bailey said.

During the first three months the patient was at Northwestern, the hospital reported three infections in that patient to the CDC.

It’s not only the magnitude of the penalty, but the publicity that comes out of being penalized.

Dr. Kevin Kavanagh

In some instances, Northwestern officials say, they have room for improvement. The hospital requires nursing supervisors and their teams to “audit” nurses at least 20 times each month by watching them as they insert and maintain catheters.

“Hand hygiene, as easy as it sounds, that takes a lot,” Andrea Stone, the nurse manager, said. “People get busy, and it’s a teaching hospital, and if you’re in a group and the doctor or the attending is talking with the entire team, people might not be as focused.”

Dr. Richard Wunderink, medical director of the intensive care unit, said Northwestern’s focus on the conditions that determine Medicare penalties has detracted from more prevalent medical challenges, such as how to reduce pneumonias in patients on ventilators, he said.

“There’s no penalty right now for pneumonias,” Wunderink said. “We are spending time on things that are maybe less important from a patient care perspective but more important from a financial perspective.”

Not every expert believes teaching hospitals are inherently more meticulous in screening patients. “I see transfers from community hospitals, and they tend to do just as many cultures as we do,” said Dr. Jennifer Meddings, an assistant professor at the University of Michigan Medical School whose research focuses on infections.

Ascher, Bilimoria’s patient with the swollen leg, praised Northwestern for its thoroughness. She has had four surgeries for melanoma on her left leg. During her treatment, doctors inadvertently discovered a brain aneurysm, which she said “they found only because they were so thorough because of the testing they did on me.”

One of the cancer surgeries led to an infection, which Bilimoria said was not unusual for the rare procedure he performed, a type that usually takes place only at academic medical centers.

“It was caught soon enough that I didn’t have any real problems with it,” Ascher, 74, said. “As far as I’m concerned, I’m at the best hospital there is, and we have lots of hospitals to choose from in this city.”

KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.

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Viewpoints: The Meaning Behind UnitedHealth’s Obamacare Exit; High Court Consideration Of Health Care And False Claims

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State Highlights: Illinois High Court To Consider State Employee Retiree Health Benefits; In Iowa, Families Press For Vaccine Exemptions

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Texas Asks Federal Officials To Renew Medicaid Funds For Hospitals

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Michigan AG To Announce Criminal Charges In Flint Water Crisis, Sources Say

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Cancer Advocacy Groups Come Out Swinging For ‘Moonshot’ Resources

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‘Smokeless Doesn’t Mean Harmless’: FDA Launches $36M Campaign Against Chewing Tobacco

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Opioid Epidemic Casts Shadow On Marijuana Legalization In New England

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Life Expectancy Dips For White Women: Statistical Blip Or ‘Harbinger Of Things To Come’?

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