August 01, 2016

The Emperor Has No Clothes

I’ve been studying Medicare’s new Hospital Compare website. Lots of people have complained about this particular ranking, which gives only 102 hospitals in the country five stars, some of them fairly obscure institutions. I’ve argued in the past that rankings are often misleading, that institutions try to game the system, and that they are often based on measuring the wrong things. But I was curious about how Boston area hospitals, hospitals that I’m familiar with, actually performed. I was particularly interested in how they compared to other hospitals in the country in those domains that Medicare chose to examine. The bottom line is that they didn’t do very well.

Not a single hospital earned five stars. The only major teaching hospital to earn four stars was Massachusetts General Hospital (MGH). And I was curious about its weaknesses: CMS reports two, in readmissions rates and in the timeliness of care. Now I’ve suggested that there may be an irreducible minimum readmission rate—the frailest, sickest patients are going to get sick again, no matter what kind of care they get either in the hospital or after they return home. The only way they aren’t going to be readmitted is if they are offered, and agree to, care exclusively at home (for example, home hospice). And unless we provide more ways that the frailest and sickest can get care at home (aside from hospice, for which not all will be eligible and not all those who are eligible will elect), and unless we discuss their goals of care and how best to achieve them, they are going to return to the hospital when they get sick again. Which they will. But it’s nonetheless striking that MGH—and every single other major teaching hospital in Boston—did worse than the national average in readmissions. That's not a problem with hitting an irreducible minimum. That's a problem achieving the achievable.

MGH’s other Achilles heel, timeliness of care, was also a problem for all the other leading Boston hospitals. Both these deficiencies suggest that the hospitals are not doing a good job of working with primary care doctors and community agencies to coordinate care, to make sure that whatever needs to get done is in fact done. That's a problem for geriatric care.

The other two principal teaching hospitals of Harvard Medical School, the Beth Israel Deaconess Medical Center (BIDMC) and the Brigham and Women’s Hospital (BWH), only managed to get three stars each. In addition to problems with readmissions and timeliness of care, they had assorted other difficulties. BIDMC’s “effectiveness” was on par with the national average, but no better. It did not demonstrate the efficient use of medical imaging. And BWH was below the national average in effectiveness and in safety. That’s disturbing.

The major teaching hospital of Boston University, the Boston Medical Center, also got three stars. It was the only large hospital that did worse than the national average in the domain of the "patient's experience," or how patients rated their stay. The principal teaching hospital of Tufts University, New England Medical Center, only got two stars, with problems in safety, readmissions, timeliness of care, and the efficient use of imaging. Not very impressive.

Two community hospitals, Faulkner and Newton Wellesley (both in the Partners orbit, the hospital system that owns MGH and BWH) got four stars. This result is a bit perplexing as Newton Wellesley, for example, was actually at (not above) the national average in safety, readmission, effectiveness of care and efficient use of imaging, and below the national average in timeliness. Evidently a bunch of B’s and only one C is deemed worse than a bunch of A’s and two C’s. The process of lumping all these measures together to get one final grade seems to me to lead to a misleading conclusion.

So I still don’t think it’s reasonable to conclude very much from the conglomeration that goes into coming up with a single rating. But I do think that observing that every single hospital in the Boston area was below the national average in at least one area and most of them, including the most prestigious institutions, were below the national average in several, is sobering. The areas Medicare chose to focus on are important for quality. There is no good reason for Boston institutions to have more difficulty with any of these measures than the national average. Boston, shape up!

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