Rating hospitals: Look beyond federal stars

By Lynn Arditi
Published August 5, 2016

South County Hospital, a 100-bed community hospital in South Kingstown that performs many knee and hip replacement surgeries, won the top, 5-star ranking in the federal government's new system of rating hospitals. Journal files/Sandor Bodo
South County Hospital, a 100-bed community hospital in South Kingstown that performs many knee and hip replacement surgeries, won the top, 5-star ranking in the federal government’s new system of rating hospitals. Journal files/Sandor Bodo

Would you want to deliver your baby at a two-star hospital?

The answer seems obvious, but it’s not.

The federal government in July released the first overall quality ratings for the nation’s hospitals, and Rhode Island’s nationally recognized birthing hospital — Women & Infants Hospital — got slapped with a below-average rating.

It’s among more than 700 hospitals in the country– including big-name teaching hospitals such as Tufts Medical Center in Boston and Beth Israel Medical Center in Manhattan — which the government rated 2 out of 5 stars, according to an analysis by Kaiser Health News, a national nonprofit news service that is part of the Kaiser Family Foundation.

The federal Centers for Medicare & Medicaid Service said the star ratings are designed to encourage hospitals to improve and empower consumers to make better health-care choices.

But many hospital officials say the rating system is at best flawed and at worst misleading. And they’re urging Washington lawmakers to retract the ratings until they fix the measurements and rerun the analysis. (The Hospital Association of Rhode Island is supporting a bill introduced in Congress to repeal the ratings.)

Modeled after the federal system used to rate nursing homes, the star ratings summarize up to 64 quality measures published on its website, Hospital Compare, including how well the hospitals treat heart attacks, the hospitals’ infection rates and deaths. The overall rating compares their performance with the average of other hospitals in the U.S.

The government rated more than 3,600 hospitals nationwide which receive Medicare payments, including 11 in Rhode Island. (Providence VA Medical Center was not rated because Medicare doesn’t pay for its services.) Eight of the 11 Rhode Island hospitals — including Rhode Island Hospital — received 3 stars, or average. The highest ratings went to two of the state’s smaller hospitals: The Miriam Hospital, which received 4 stars, and South County Hospital, which won a 5-star rating. The 100-bed community hospital performs about one-third of all hip and knee joint replacements in the state, a hospital spokeswoman said.

Hospital officials say a major flaw of the rating system is that it lumps together very different types of hospitals that serve vastly different patient populations. Teaching hospitals, such as Rhode Island Hospital, which serve more urban centers with poorer, sicker patients, tended to score lower than smaller, community hospitals in suburbs that provide more routine care. The government does adjust for the health of patients when comparing hospitals, but not to the extent that hospital officials say it should.

The ratings also are meant to measure routine care, which is different from the services provided at specialty hospitals, such as Women & Infants, said Dr. Atul Grover, executive vice president of the Association of American Medical Colleges, a nonprofit professional organization based in Washington, D.C. Many of the measurements designed for general surgical hospitals, he said, simply don’t apply to specialty hospitals.

“They’re attempting to compare apples with oranges,” Dr. Grover said.

If a hospital doesn’t provide a specific clinical service measured by Medicare, the data for the remaining measures weighs more heavily in its overall score, said Dr. Robert Insoft, Women & Infants’ chief medical officer and senior vice president of quality affairs. Women & Infants’ 2-star rating was based on its performance in just 32 of the 64 areas measured, he said, which skews the results.

The ratings are also based solely on data for patients enrolled in Medicare, the federal health-insurance program that serves people 65 and older and those with disabilities. Medicare patients make up just 1.3 percent of those hospitalized at Women & Infants but nearly 50 percent of those hospitalized at South County.

Women & Infants scored far above the national average in preventing premature births, and average or better than average in health-care related infection rates. But it got dinged on its rating for complications from surgeries other than C-sections. The hospital’s “serious complications” rate was worse than the national rate.

Dr. Raymond Powrie, chief medical quality officer for Care New England and a senior vice president at Women & Infants, said the hospital’s complication rate is higher because its doctors routinely operate on women with “complex and advanced gynecological malignancies, and generally those cases carry a higher complication rate.”

Even so, Powrie said, the hospital takes these ratings seriously and has examined every chart to understand what’s behind the numbers. “Every single surgical complication that happens is reviewed in detail with experts and with other peer physicians,” he said.

Women & Infants’ access to specialists and advanced diagnostic and therapeutic technologies, he said, means that it’s often the first place other area hospitals refer their most complex gynecological cases — a distinction that may serve to drive down its performance rating.

Similarly, a patient who has a stroke and shows up at South County Hospital — the state’s only 5-star hospital — would probably be referred to Rhode Island Hospital, southeastern New England’s only hospital with a comprehensive stroke center, said Dr. Cathy Duquette, executive vice president of nursing affairs for Lifespan, the nonprofit parent of five hospitals in the state including Rhode Island Hospital.

Rhode Island Hospital also is the only “level 1” trauma center in the state, as designated by the American College of Surgeons, which means it cares for the most seriously injured patients.

“It’s not a level playing field in any regard,” Martha W. Murphy, a spokeswoman for South County Health, the nonprofit that includes South County Hospital, said of the ratings. “But that does not take away from the accomplishments here at South County Hospital.”

So how are consumers to evaluate the quality of Rhode Island’s hospitals?

In addition to complication and readmission rates, Dr. Insoft said, volume of surgeries performed and teaching environment also correlate with high-quality care. The same hospital may score very differently depending on what is being measured.

Leapfrog Group, a nonprofit, grades hospitals on how well they prevent medical errors, infections and other safety measures. Leapfrog recognized Women & Infants Hospital in its annual list of Top Hospitals in 2014 for excellence in safety and quality. The Leapfrog survey covered some of the same time period as the Medicare survey, “only weighted differently,” Mark R. Marcantano, the hospital’s president and chief operating officer, wrote in an employees’ newsletter released last week.

“No hospital rating is perfect, including our own,” Erica Mobley, director of communications at Leapfrog. “But it’s important not to let perfection be the enemy of good.”

To evaluate hospital quality, Mobley said, consumers need to look beyond the government’s star ratings and consider “multiple ratings.”

So if you’re a consumer searching for a high-quality hospital, whether for elective surgery or to deliver your baby, Mobley and hospital officials recommend checking readmission and complication rates, along with volume of surgery performed and academic affiliation. And always, they say, consult your physician.

But for now, they agree, you won’t find the answer in the stars.

Where to compare

CMS: Hospital Compare

Consumer Reports: Doctors and Hospital Ratings.

ProPublica: Surgeon Scorecard

The Leapfrog Group: Hospital Comparisons.

U.S. News & World Report: Best Hospitals.

AHCJ’s HospitalInspections.org

— larditi@providencejournal.com

(401) 277-7335