What’s a good hospital? The one good enough in a life-or-death event – the nearest emergency department for a heart attack – may not best when you have time to plan for a heart bypass, knee replacement or hysterectomy.
Truth is, the wellspring of informed intelligence for patients on medical decision-making is murky and likely will take years to clarify.
Irrespective of the Affordable Care Act, reform was urgently needed for our episodically wonderful and nearly indecipherable health system.
But the critical conversion from volume-driven payment to pay-for-performance – quality outcomes borne of cost-effective, best practice medicine – hasn’t yet resulted in a universal, reliable value-driven scale. Sure, the jargon bandied about is sensible enough for Google News readers – centers of excellence, star ratings, the patients’ choice.
Consumers are being told what they want to hear and where they ought to seek care. But there’s no definition – among insurers, providers and regulators – on a single set of benchmarks to separate fair, good, excellent and execrable. No one has created a medical Federal Reserve Board to oversee and certify best practices and practitioners.
Yes, the Joint Commission, the premier hospital evaluating body, has certification programs. So do insurers and organizations like the National Cancer Institute. But it’s not clear if they share their criteria or evaluation methods.
Consumers are still tasked with substantial, Byzantine self-education. So, in a Yelp world, how about a star ratings system for hospitals? That major controversial step occurred last July.
The Centers for Medicare & Medicaid Services released its first star ratings for hospitals based on 64 quality measures ranging from patient satisfaction, to mortality, readmissions and safety and effectiveness of care.
Few hospitals earned five stars; some prestigious names earned one. The Central Valley had one five-star facility (Fresno Surgical Hospital) and one of the state’s and nation’s lowest (Tulare Regional Medical Center with one star). Even those who did well criticized the methodology.
Consider a few of the wild cards involved.
Take readmissions. Not every hospital operates an emergency department, and even fewer are teaching hospitals which educate future physicians.
Hospitals which have both, like Fresno’s Community Regional Medical Center, are likely to see more patients with multiple chronic illnesses that have sporadically, if ever, received medical attention. They arrive in bad shape, take longer to leave the hospital as an inpatient and are more difficult to place with follow-up continuing care. For socioeconomic reasons, their progress may be hard to track. As a result, many are readmitted within 30 days of discharge for their same problems.
The result: Such hospitals may be hit with federal financial penalties. And their star ratings suffer.
How about patient experience? One survey aspect involves querying how pain is being addressed. Pain management is a complex science that factors in a patient’s ailments, age, other medications – and whether substance abuse is an issue. Here again, safety-net hospitals get hit harder on ratings that those that don’t have emergency departments or take Medicaid patients.
“They liken or cheapen medicine to a 4-star hotel rating,” one longtime Valley physician told me.
Fact is, being held to a very public standard of accountability – however shaky it now is -- insults some, infuriates a few and encourages those who believe in a more holistic, transparent approach to well-being.
“Administrators know the lay person cannot ascertain truth concerning quality care nor can they define it,” my physician friend said. “It is an experience! And the image is part of the experience.”
Many folks don’t know anything about their caregivers – their training, what they do well and, more importantly, what they do rarely or poorly. Patients may not know an endoscope from an angiogram. They trust and do what they’re told.
They don’t research (asking Siri doesn’t count).
The myriad of ratings and possible excellence centers is, at best, a convoluted start for the clear, sustaining education that consumers – and caregivers – urgently need.
(Also published as an op-ed in the Sept. 24, 2016 edition of The Fresno Bee.)