Life Science Compliance Update

September 01, 2015

Hospital Compare Survey Of Patient Experience: Highest Scores For Small, For-Profit Hospitals; Lowest to Large, Teaching, Safety Net Hospitals

Hospital Compare

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) added a new star rating system to its Hospital Compare website based on patients’ appraisals. CMS created the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Star Ratings "to enable consumers to more quickly and easily assess the patient experience of care information that is provided on the Hospital Compare website." The rating is a composite of 11 facets of patient experience—such as how well doctors, nurses, and hospital staff communicate, the "cleanliness" and "quietness" of the hospital environment, and whether patients would recommend the hospital to others. Hospitals collect the reviews by randomly surveying patients after they leave the facility.

Medicare assigned star ratings to 3,553 hospitals based on the experiences of patients who were admitted between July 2013 and June 2014, according to an analysis in Kaiser Health News. Medicare awarded the top rating of five stars to 251 hospitals, about 7 percent of all the hospitals. Medicare gave out four stars to 1,205 hospitals, or 34 percent of those it evaluated; 1,414 hospitals, 40 percent, received three stars; 582 hospitals, or 16 percent, received two stars. Three percent, or 101 hospitals, received a one star rating.

A new article on Kevin MD dove deeper into these results. It found that "large, non-profit, teaching, safety-net hospitals located in the northeastern or western parts of the country were far less likely to be rated highly (i.e., receiving 5 stars) than small, for-profit, non-teaching, non-safety-net hospitals located in the South or Midwest."

The differences between the groups were huge. According to the article's analysis:

There were 213 small hospitals (those with fewer than 100 beds) that received a 5-star rating. Number of large hospitals with a 5-star rating? Zero. Similarly, there were 212 non-teaching hospitals that received a 5-star rating. The number of major teaching hospitals (those that are a part of the Council of Teaching Hospitals)? Just two — the branches of the Mayo Clinic located in Jacksonville and Phoenix. And safety net hospitals? Only 7 of the 800 hospitals (less than 1 percent) with the highest proportion of poor patients received a 5-star rating, while 106 of the 800 hospitals with the fewest poor patients did. That’s a 15-fold difference. Finally, another important predictor? Hospital margin — high margin hospitals were about 50 percent more likely to receive a 5-star rating than hospitals with the lowest financial margin.

These results don’t seem too surprising given that many of the patient satisfaction metrics seem likely to be affected by the amenities or comforts of a given hospital. Large teaching hospitals or safety net hospitals likely will not be as consistently quiet or likely voted to be as clean as a small for-profit hospital with fewer patients.

“America’s Essential Hospitals,” a trade group representing about 250 hospitals that fill a safety net role in their communities, recently articulated concerns its members had with the star rating system to CMS. Like the survey on Kevin MD, their letter to the agency noted: “our research shows there is the distinct risk that larger hospitals, teaching hospitals, and hospitals serving a high proportion of low-income patients will receive lower star ratings while still providing quality care, often to the most vulnerable” (emphasis added). Further, the group wrote that “the proposed methodology oversimplifies complex and individualized choices patients must make about their health.”

In addition to star ratings for patient experience, CMS has signaled that they will be introducing star ratings for other aspects of "quality," including patient readmissions and complication rates. These metrics currently have more detailed information, which hasn't yet been consolidated into a 1-5 star rating. 

America's Essential Hospitals offered their input into how CMS should move forward with their star rankings. CMS's methodology "should incorporate risk adjustment for socioeconomic factors so results are accurate and reflect differences in the patients being treated across hospitals," the letter states. "Without proper risk adjustment, an essential hospital, serving a disproportionate share of lower-income patients with confounding sociodemographic factors, might be rated lower for reasons outside its control." For example, "[r]ace, homelessness, cultural and linguistic barriers, low literacy, and other socioeconomic factors can skew results on certain quality measures, such as those for readmissions."

"It is well known that patients who lack reliable support systems after discharge are more likely to be readmitted to a hospital or other institutional setting," writes America's Essential Hospitals. "These readmissions result from factors beyond the control of providers and health systems and do not reflect the quality of care provided."

Download the full letter to CMS here.

August 31, 2015

EHR: Congress Moves to Delay and Modify Timeline for Meaningful Use


There is a growing movement in Congress to push the Department of Health and Human Services (HHS) to postpone Stage 3 of the electronic health record meaningful use program. Recently, Rep. Renee Ellmers (R-N.C.) introduced a bill (HR 3309) that would delay federal rulemaking for Stage 3 of the meaningful use program until 2017 or when certain conditions are met. Under the proposed Stage 3 rule, eligible providers would have the option of applying for the incentives in 2017 and would have to attest to meeting the criteria in 2018. The comment period on the proposed rule ended May 29, and the CMS is expected to finalize it soon.

During a hearing on meaningful use Stage 3, interoperability and patient access to data, Sen. Lamar Alexander (R-Tenn.) stated: "To put it bluntly, physicians and hospitals have said to me that they are literally terrified of the next implementation stage ... because of the complexity and because of the fines that will be levied,” Fierce Health IT writes.

Industry and Medicine’s Response

As reported in Medscape, industry's response to the Stage 3 proposal has been mainly negative. The Medical Group Management Association (MGMA), for example, said that Stage 3 should not be finalized until more providers had participated in Stage 2. As of May 2015, just 50,983 eligible professionals and 1461 eligible hospitals had attested in Stage 2, according to the CMS. The MGMA also wants CMS to eliminate Stage 3 objectives that require patient engagement.

The American Medical Association (AMA) also criticized the proposal, saying more time is needed to evaluate the impact of the first two stages and that the Stage 3 criteria were too ambitious. And both the American Hospital Association and the College of Health Information Management Executives (CHIME) said the CMS should not finalize Stage 3 until it had had more experience with Stage 2.

It comes as no surprise the AMA strongly supports Congressional intervention to delay Stage 3. "The AMA thanks Rep. Ellmers for sharing our deep concern with a Meaningful Use program that continues to move ahead without first fixing barriers faced by physicians, hospitals, vendors and patients," said AMA President Steven J. Stack, M.D. "Under Rep. Ellmers' leadership, federal regulations would be revised to provide greater flexibility for physicians to meet the Meaningful Use requirements and ensure that Stage 3 of the program is developed in step with other efforts to modernize our nation's health care system."

The bill also addresses key interoperability challenges by ensuring EHR systems are capable of sending, receiving, and seamlessly incorporating patient data.

"This important bill addresses many of the fundamental shortcomings in government regulations that have made many EHR systems very difficult to use," said Dr. Stack. "We heard loud and clear from physicians at the AMA's first-ever town hall meeting on EHRs and the Meaningful Use program that the systems they use are cumbersome, poorly designed and unable to 'talk' to each other thereby preventing necessary transmission of patient medical information."

Struggling to Adopt

Physicians are struggling, as noted in a recent AMA report. One physician the article profiled is in his fourth year of meaningful use, and said the program has slowed down productivity in his practice by about 25-30 percent.

“There are so many more things that you have to report on that I don’t think really add to patient care,” the doctor said. “I’m trying to work with it. I think meaningful use is not necessarily a bad thing. But I don’t think [patients] have an idea what we’re going through. To give them a copy of their note, it’s not just printing it … there are four or five steps just to give somebody a copy of their note.”

The government has known about the problems cited by physicians for a long time. Back in May 2014, CMS delayed for a year the compliance date by which certain early participants in the program meet Stage 2 requirements. The relatively high percentage of providers—62%—still stuck on Stage 1 in the fourth full year of the program bears out the wisdom of the CMS' Stage 2 compliance extension.

The latest data tracks with an analysis done earlier this year by the American Academy of Family Physicians, according to Dr. Steven Waldren, director of the AAFP's Alliance for eHealth Innovation. Waldren said the number of family physicians who attested to meaningful use in 2014 fell nearly 40% to about 23,500 practitioners compared with 2013. Physicians specializing in internal medicine experienced a similar drop-off, he said.

Additionally, a new study from Weill Cornell Medical College describes the emergence of "systematic differences" between physicians who participated in the Medicare and Medicaid EHR Incentive Programs and those who did not. That "could lead to disparities in patient care," according to Weill Cornell researchers, who examined 26,368 physicians across New York State, using payment data from 2011 to 2012, the first two years of meaningful use.


This issue raises serious questions for broader federal health care goals. As we previously wrote, HHS aims to tie 30 percent of payments to quality, including the use of electronic records, by the end of 2016, and 50 percent by the end of 2018. The new MACRA legislation and recent CMS Medicare proposed rules operate as if meaningful use is moving forward as scheduled. Should Congress delay implementation of the next stage of meaningful use, it could have a ripple effect across HHS goals, possibly causing added confusion for physicians and hospitals. It will be important to monitor this as it develops; legislation may need to be passed soon, as CMS wishes to finalize its Stage 3 meaningful use regulations.



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