Newly uncovered documents detail the sugar industry's use of Harvard researchers to downplay the link between cardio-vascular disease and sugar. The corrosive effects of this deceit are playing out today with epidemics of obesity and coronary heart disease.
An exposé published online this week in JAMA Internal Medicine provides a glaring example of why many Americans are distrustful of those who claim to speak for the public good.
Papers found in Harvard University archives provide smoking-gun evidence that the sugar industry in the 1960s conspired and paid academics at the prestigious school (about $50,000 in today's dollars) to publish skewed research reviews in The New England Journal of Medicine that obfuscated and downplayed the linkage of sugar and coronary heart disease.
"The Sugar Research Foundation had a very sophisticated understanding for the time of the potential health risks associated with sugar use," said Stanton Glantz, PhD, one of several authors of the exposé, and a professor of medicine at the University of California – San Francisco, in an interview accompanying the JAMA story.
"They reached out to some well-known professors at Harvard University and funded them to write a review of the available literature on dietary determinants of heart disease. In the review, the Harvard authors really downplayed the evidence linking sugar and triglycerides and heart disease and emphasized the evidence linking fat intake with heart disease."
Sweet Dividends
The investment by Big Sugar paid sweet dividends, as the misdirection proved extremely influential in the years ahead. "By downplaying and really dismissing sugar's connection to heart disease through triglycerides in this editorial, it helped to derail a discussion of the issue for decades," Glantz said.
There is a certain "No duh!" element to this story. It is no secret that every industry in every sector of the economy attempts to sway the "disinterested" expertise of prestigious scientific and academic institutes to validate their pro-industry perspective, and bottom line.
Even by those jaded standards, this case is egregious, not just for who did it and how they did it, but for the damage it did.
The deception is 50 years old but the effects are still felt as the nation deals with twin and related epidemics of obesity and coronary heart disease. Much of that can be traced to a steady diet of junk foods packed with processed sugars. One can only guess at how many millions of lives were ill-effected by this deception.
The good news is that most research papers published in reputable journals now must disclose funding sources.
Well, sort of. "Even disclosure doesn't do that much," Glantz said. "When reviews and scientific research like this get published, they sort of get swept up into the broader scientific and policy debates where the question of who funded what often gets ignored."
"It isn't so much a matter of falsifying data, it's a matter of what you emphasize and de-emphasis and how you spin it," Glantz said. "Work funded by any interest with a vested interest in the outcome needs to be looked at extremely skeptically, if not discounted entirely."
Repercussions for Providers
For providers, this revelatory JAMA piece may have trickle-down implications in their one-on-one relationships with patients.
This story is already percolating through the mainstream media and will likely be the fodder of conspiracy theorists. Anti-vaccination advocates, for example, whose own agenda is built on fraudulent research, might see this expose as gas-on-the-fire proof that big business is in cahoots with medicine and cannot be trusted.
Others will suggest that the sugar industry pushed for fluoridated water to cover their tracks and mitigate the effects of more sugar in the diet. When special-interest money taints research it also corrodes trust, and those concerns cannot be casually dismissed.
When patients were treated at high-quality hospitals, Medicare spent $2,700 less in the first 30 days than it did for patients at low-quality hospitals, researchers have found.
High-quality hospitals might cost Medicare more on the front end but they save money in the long term researchers have concluded.
Researchers at Harvard's T.H. Chan School of Public Health examined Medicare costs and outcomes data between 2011 and 2012 for five major surgical procedures—coronary artery bypass grafting, pulmonary lobectomy, endovascular repair of abdominal aortic aneurysm, colectomy, and hip replacement.
High-quality hospitals were identified by 30-day surgical mortality rates and patient satisfaction scores.
Beyond the initial $32,000 average cost for the surgeries, the researchers calculated costs of the procedures and post-surgical care at both 30- and 90-day periods among 110,625 and 93,864 Medicare beneficiaries, respectively.
When patients were treated at high-quality hospitals, Medicare spent $2,700 less in the first 30 days than it did for patients at low-quality hospitals, and $2,200 less at 90 days after accounting for all the differences in patient populations, according to the study, which appeared in Health Affairs.
Nearly two-thirds of Medicare's savings were driven by lower use of post-acute care services by patients at high-quality hospitals compared with those at low-quality hospitals.
Study senior author Ashish Jha, MD, MPH, spoke with HealthLeaders Media about the findings. Jha is a practicing general internist at the VA, a professor at the Harvard Medical School, and a member of the Institute of Medicine. The following is an edited transcript.
HLM: What prompted this study?
Jha: We have found that delivering high-quality healthcare costs more money. So we thought, "maybe surgery is different. When you have a surgical procedure and it goes well, because you are at a good institution that does a good job, maybe you end up saving a lot of the costs of complications that follow."
HLM: That was the motivation for this study: Does that turn out to be true?
Jha: Of course, there is one countervailing force. If you are a high-quality hospital, you are going to keep more patients alive.
That means there are some people who are really sick who would have died at another institution that survive at yours. Those people end up costing a lot of money.
That actually made us worry when we began this project: Would the costs associated with that swamp any savings we might get from being generally good quality?
We found that no, they would not. High-quality hospitals have fewer complications, they have fewer people coming back for readmissions, and less post-acute care services.
All of that ends up saving the system a lot of money. Of course, it is also much better for patients.
HLM: Your findings seem to support the old notion that "you get what you pay for."
Jha: Yes, and no. We are finding that it's better to be in a Mercedes than a Kia, but at the same time Medicare is paying both the same amount, and that is a problem.
Medicare will come back and say, we have some programs that on the margins award hospitals for these measures. But it's very little compared to the benefit that Medicare is getting.
Medicare saves $2,000 to $3,000 every time a person goes to a high-quality hospital instead of a low-quality hospital. [But] let me assure you that the high-quality hospital isn't getting paid $3,000 extra for that procedure.
HLM: Were you able to factor out the socio-demographics of the patient mix?
Jha: We were worried about that, so we adjusted for a series of things, including the underlying patient population differences between the high- and low-quality institutions, just to make sure that what we were picking up was something different than a population that is served by these hospitals.
We did find that low-quality hospitals tended to have more poor patients and we wanted to make sure what we were picking up was really quality and not poverty. So we adjusted for that the best we could. Is that adjustment perfect? No. Does it get at most of that difference? I think it does.
HLM: How did patient experience play a factor in this study?
Jha: There is now good evidence that institutions that have good patient experience tend to do a lot of things well.
If you think about patient experience questions , [such as about how doctors and nurses communicate and respond to a patients needs and issues,] institutions where physicians and nurses are communicating well with patients are probably also communicating well with each other.
They are part of an institution where communication and information flow is generally quite good. That probably helps out in terms of making sure that complications are identified early.
HLM: Are there any alternative explanations for your findings?
Jha: Those issues of underlying patient population differences are still out there and they are not fully settled. The only way to fully settle those issues is to do a randomized trial. Send some people randomly to high- and low-quality hospitals and see what happens. Well, that is not going to happen.
Barring that, we are left with these other techniques that don't get us all the way there, but get us a large chunk of the way here. It's hard for me to imagine that it is just patient population differences that explain these fairly sizable differences in spending.
HLM: What would you like to see done with these findings?
Jha: This study should be a strong impetus for Medicare and other payers to reward high-quality institutions more than giving them a tiny bonus or penalty.
We should be rewarding high-quality institutions with more financial resources, and at the same time, really penalizing low-quality institutions, because not only do people do badly there, they end up spending more money.
The system should take that into account. Right now we are paying the same for a Mercedes versus a Kia.
The Iowa-based health system's Remote Patient Monitoring program looks to deliver on its promise to improve rural population health and reduce readmissions and ED visits by using targeted interventions.
Over the past two years, the Quad State-area health system headquartered in Des Moines, IA has slowly rolled out an updated and enhanced remote patient monitoring program through its UnityPoint at Home division. If the program works as promised, it will reduce readmissions and ED visits, while improving outcomes and maintaining health for the chronically ill population it serves.
"When you have a remote patient monitor, the goal is to help them self-manage their chronic conditions because they are going to have it long-term," says Vicki Wildman, RN, virtual care director UnityPoint at Home.
"Generally, the patients benefit most when they are acutely sick, and we need close tabs on them to best coordinate that care for the 60-days post-acute hospital stay. How are their meds doing? How is their weight? Are they on fluid overload?"
UnityPoint at Home RPM communicates with about 600 chronically patients at any given time through wireless, tablet-based encrypted videos. Most of the patients are seniors on Medicare, ages 65 to 100, and the most common chronic ailments include heart failure, high blood pressure, stroke, lung problems, and dehydration.
"These are the people in the care gap of the health system who are treated episodically who are struggling with chronic health management, which for many, if not most of them, there is no cure for. So, it's about quantity and quality of life," Wildman says. "These are the 5% of your healthcare system [population] that are using 50% of your healthcare resources who need the frequent monitoring."
RPM patients are given pre-programmed kits that accommodate their specific health concerns, and include a Samsung wireless tablet, a wireless blood pressure cuff, pulse oximeter, and scale.
Vital signs are transmitted daily from the patients' homes to telehealth nurses in 13 homecare offices in the multistate service area. The telehealth nurses provide patient education, "virtual triage," and other assessments while coordinating care with the patients' providers.
Wildman says that about 60% of the patients have the RPM shipped to them and complete the set up remotely with the help of a customer service contact, while 40% of the patients require some sort of home visit to get their RPM operational.
UnityPoint at Home has been working with telehealth since 2000, and launched the slow rollout of the upgraded RPM program two years ago.
In 2015, 1,791 patients participated in RPM. The HIPAA-compliant kits cost about $1,500 each, patient use them for an average of 45 days, and Wildman expects that on average four patients will use each tablet before a technological upgrade is needed, at a cost of about $430 per tablet.
The cost is covered, somewhat, under Medicare and some commercial plans.
"There are some monthly costs with telehealth that are going to be hidden in there," Wildman says. There are "communication and user fees that come into play. With that said, if a patient were to participate as a private pay, our fair market analysis, by the time you add the nursing oversight, care coordination, logistics, shipping and all that, is about $10 per patient per day."
The return on investment is still being calculated because the program upgrade is still a work in progress. However, UPH data shows that patients who have heart failure and aren't using RPM are four times more likely to go back to the hospital in the first seven days after a hospital stay.
"When you think about the ROI of telehealth, it's not just the tools and equipment," Wildman says. "What we're wanting is cost avoidance."
Anecdotally, Wildman says the response has been positive from most patients, many of whom say they feel more engaged in their care management.
"We know that some patients have had great success stories, who used to have six or seven ED trips or hospitalizations that haven't had one in a year," she says.
"What determines transition out of the program is patient collaboration and their ability to self-manage and self-monitor, and that they have a transition plan to be under the care of a provider. That is our ultimate goal, to get them moved to their provider."
Physicians spend two-thirds of their day completing tasks on cumbersome electronic health records systems. It's a leading cause of physician burnout, research shows.
The electronic medical records that came with a promise of improving care efficiency are instead forcing physicians to spend more face time with a computer screen than with their patients.
An observational analysis and survey of 57 primary care and specialty physicians in four states that was detailed this week in Annals of Internal Medicine shows that for every hour a physician spends providing direct clinical face time with a patient, nearly two additional hours are spent on EHRs and administrative tasks.
The time it takes to record a wide array of EHR data points has become a leading factor in physician burnout, says study lead author Christine Sinsky, MD, a Dubuque, IA-based internist, and vice president of professional satisfaction for the American Medical Association.
Sinsky spoke with HealthLeaders Media about her study. The following is an edited transcript.
HLM: Are you surprised by these findings?
Sinsky: We expected there would be a large portion of the day directed toward EHR and administrative tasks, but the extent we found was more than we expected.
HLM: What's driving this?
Sinsky: It's a cumulative effect of many well-intentioned interventions in healthcare. More specifically, EHR simply takes longer than it does in the non-EHR world.
On top of that, the EHR has become the vehicle for implementing other ideas that may be helpful toward improving healthcare, performance measurements, and additional data collections. These may have some benefits, but they have also had this downside of consuming more and more physician time.
HLM: Wasn't the whole idea of EHR to make care more efficient?
Sinsky: That was the hope, but it's a hope that has not been realized across all the tasks of care. There are some tasks that probably are more efficient with EHR but there are many tasks that take longer.
In my own practice some tasks, such as indicating the next test or treatments for patients, might take three-to-five seconds to orchestrate with a paper check list. Now that takes two to three minutes through the EHR. If you multiply that difference by the number of tasks that physicians and clinical staff do every day, it adds up to a large portion of the day.
HLM: How did it come to this?
Sinsky: Any individual initiative sounds like it only takes a minute or two to record this element or create this discreet data point, but then it adds up to what we've found in our study, which was that physicians were spending a large portion of their day not providing direct care to the patient but rather doing EHR and desk work.
HLM: Is this a learning curve issue that might improve as physicians get more comfortable with EHR?
Sinsky: That is a myth. This is a technology and regulation and implementation issue. These are not findings that are limited to a small segment of the physician population but are across the board.
HLM: Is it possible that this is time consuming on the front end, but that it leads to other efficiencies later in the care continuum?
Sinsky: I don't think that any of our practices in the study were new to an EHR. They were in a steady state. It wasn't about the first six months of getting all the patients demographic data into the record that was causing the problem.
HLM: How is this affecting the physician-patient relationship?
Sinsky: Most patients who have visited a physician in the past several years are aware that they are not getting the direct undivided attention from their physician that they've had in the past that they know is important to their care.
They know that physician has to divide their attention between them and the electronic health record. One common complaint is that their doctor isn't giving them eye contact or listening intently. Physicians hear that sense of dismay that the relationship has been altered by EHR.
HLM: Can someone else do that data entry?
Sinsky: Advanced team-based models of care, where a clerical or clinical assistant helps with record keeping, has been one of the solutions to allowing the physicians to maximize their skills for the benefit of the patients. But there is simply a lot more data entry work than in the past.
We need to reconsider the notion that physicians are the appropriate team member to do data entry. That is not giving society the best return on investment in training of physicians.
One doesn't need 11 years of training to do any of the data entry and retrieval tasks that are so time consuming with EHRs. Very few other industries take their most highly trained individuals and have them spend the majority of their day that another employee or team member could do. It's time for us to reconsider that role in medicine.
HLM: What other solutions do you recommend?
Sinsky: We need EHRs that are designed to delight the users and right now that is not one of the criteria. We need to count up the number of clicks to do the task and compare that across different products. For example, with my EHR it takes 32 clicks to document giving a flu shot. I would love to see vendors compete on the ability to reduce the number of clicks to do a task.
HLM: What are the physicians in your study saying in their diary entries?
Sinsky: The main takeaway, and this is a good thing, is that physicians are driven to deliver quality care for their patients and anything that gets in the way of that is a source of burnout.
The physicians feel responsible for absorbing those external threats to delivering quality care and protecting the patients. But it's come to the point where physicians can no longer keep absorbing more clerical tasks and still do the work for which we have been trained.
HLM: What should be done with your findings?
Sinsky: First of all, it is helpful to see what is going on, the anatomy of the physician's day, to understand the magnitude of the time that is spent on administrative and clerical tasks.
Then we need to have greater adoption of some of the innovations that have been initiated across the country to bring the physician back to full attention for the patient.
I would love it if organizations read this study and then began doing their own pilot innovations with advanced team-based models of care. Regulators can look at the study and start to reflect on the cumulative effects of the many well-intended regulations that are having the unintended opposite effect on the quality of care that patients receive.
Providers air frustrations at a plan by Gov. Sam Brownback to nearly double a tax on inpatient revenues to offset the funding gap created by the governor's 4% cut to the privatized KanCare Medicaid program.
For obvious reasons, healthcare provider associations and lobbyists are a diplomatic bunch. They loathe public confrontations with elected state officials who can raise and cut taxes, and who control funding for Medicaid, which is one of the biggest items in any state budget.
So, it was unusual to see the Kansas Hospital Association last week offer a strongly worded criticism of Gov. Sam Brownback's proposal to cut Medicaid spending by 4%, and cover the hole by what would have to be the nearly doubling of a 1.38% assessment tax on hospital inpatient revenues.
"The governor seems to be saying that in order to reverse the 4% rate cuts, he is going to increase a tax on the very entities those cuts are hurting," KHA President and CEO Tom Bell said in an op-ed column offered to newspapers across the state.
"The governor's hospital tax increase, just like his Medicaid cut announcement, shows a lack of understanding of the interdependence of Kansas hospitals specifically, and the Kansas healthcare system in general. All hospitals are challenged by the Medicaid cuts and all hospitals will be even more challenged by an increase in the hospital provider tax. And, consequently, every community, large and small, will feel its effects."
Bell told HealthLeaders Media he wrote the op-ed piece because he was frustrated by a problem with an obvious solution.
The way hospitals see it, the governor has resorted to a convoluted scheme that robs Peter to pay Peter while forfeiting about $1.2 billion of Affordable Care Act dollars that would have been available if he expanded KanCare, the privatized Medicaid program that he created.
"We feel have been great partners with the state in trying to make our KanCare program work," Bell says.
"We've been good partners through many times when there had been implementation issues, through times when we feel like policies have been instituted that would not make the program better. We've got to point out that this program can be made better by taking a hard look at it and looking at expansion at the same time."
Not a Done Deal
The ill effects of the governor's proposal would fall heaviest on rural Kansans. While critical access hospitals would be exempted from the direct 4% cut to KanCare, Bell says, they would not be exempted from the inpatient revenue tax hike. In addition, physicians and long-term care facilities serving those rural areas would see their KanCare reimbursements cut.
Brownback's proposal is not a done deal. The KanCare cuts require the approval of the Centers for Medicare & Medicaid Services. The tax hike on inpatient revenues has to be approved by the next Kansas Legislature, which may be less receptive to the governor's agenda after the November elections.
Already this month, firebrand conservative Republican supporters of Brownback's radical tax cutting philosophy were defeated in their party primary elections, which many observers saw as a referendum on Brownback, who is tanking in the polls.
"The legislature that is coming to Topeka in January will be much more interested in having this thoughtful discussion about KanCare expansion and trying to work out a program that not only supports vulnerable populations but is also is good for the Kansas economy," Bell says.
He believes the primary election was a sign that people are tired of politics taking precedence over sound policy.
"From a healthcare perspective, there has been a growing disconnect between the process hospital people go through every day at work and the political process, which is to lay blame and point fingers," he says.
"That is one of the reasons that our folks have become frustrated. They see a lack of movement toward trying to solve a problem and instead just blaming whomever."
The Louisiana Rural Health Association is asking for donations of money and healthcare supplies on behalf of rural clinics that were wiped out in this month's rain-fueled disaster.
Recovery efforts are underway for wide swaths of southern Louisiana, which last week endured epic flooding after historic rains that accumulated as much as 30 inches in two days in some areas.
At least three federally qualified rural healthcare facilities were rendered inoperable in the flooding that devastated much of southern Louisiana last week, and providers there are asking for help with the recovery.
"In most rural communities, these providers are the only option for residents to see a primary care provider," Fontenot says. "We're encouraging everyone to consider making a donation to the #OneRural fundraising campaign to help Louisiana's rural providers and/or donating supplies."
Peggy Gautreaux, owner of Total Family Medical, told local media that her facility lost everything in the flood. "We walked out with a box of Band-Aids and 10 alcohol wipes," she told WLOX-TV. "You've lost your business, but where are your patients? And what do they need? And what's going to happen to them?"
The disaster hit areas of southern Louisiana that under normal circumstances are not affected by flooding. As a result, the clinics and many other businesses and homes in the area, were not carrying flood insurance. There's no telling when they'll reopen.
"Once they're flooded, you have to gut the building, take out all the sheet rock just in case they can save the building and rebuild. If not the mold takes over immediately," Fontenot says. "They were seeing patients in the parking lot who needed services until they could move into another site. They are putting their patients first over trying to get the clinic set up, but they still need supplies."
Specifically, Fontenot says, the clinics need:
8, 23, 25 gauge needles
Gloves
2x2 and 4x4 gauze
Alcohol swaps
Laceration kits
4.0 silk suture
3 cc syringes
Sterile urine cups
Band-Aids
Donors of supplies are asked to coordinate their efforts through Fontenot.
"Some of the suppliers can't get to the area, but some of us who are closer can get there through using the backroads," Fontenot says, "so, we are asking for any supplies or donations to come to LRHA and we will be able to deliver them."
On other fronts, Fontenot says disaster coordination between providers and the state and federal agencies has greatly improved since the Hurricane Katrina fiasco.
"There were definitely lessons learned," she says.
"We have been working hand-in-hand with the Department of Health and the Office of Rural Health as far as having a contingency plan, having health standards, and being a direct contact for those clinics that have lost everything."
"Typically, when you reset a clinic you have to go through so many certifications and requirements. But we learned from Katrina that patients need services, so the state is working with [providers] to allow the clinics to be set up in temporary locations."
Louisiana Hospital Association President and CEO Paul Salles says hospital services could face months of disruption as thousands of stressed-out employees struggle to put their lives back together.
The waters are receding in flood-stricken Louisiana, but for many residents there the nightmare has just begun.
By some estimates, more than 60,000 homes have been damaged, prompting hundreds of thousands of residents to find temporary housing with family, friends, or at shelters.
So far, at least 106,000 people have registered for federal disaster aid, including many who work at hospitals in the afflicted areas. Louisiana Hospital Association President and CEO Paul Salles spoke with HealthLeaders Media about the recovery efforts. The following is an edited transcript.
HLM: How many hospitals were damaged in the flooding?
Salles: The damage to hospitals, from a property perspective, was fairly minimal. The impact to the hospitals primarily is to their staff. We're hearing that more than 5,000 hospital employees have been impacted.
The floods really impacted about 20 parishes in south Louisiana and we are receiving estimates from hospitals now that as many as 25% to 30% of their employees, and some even more than that, have been impacted severely with flooding in their homes.
HLM: Has attendance been a problem?
Salles: Attendance is a big problem. Obviously in this past week, and in the weeks to come, people's ability to get to work will be a challenge. But they're also dealing with a home that has had three or four feet of water in it and that will continue to be a huge issue.
We had areas of south Louisiana that received 20 to 30 inches of rain over a couple of days. Many of the areas that were flooded were not in historical flood areas, so many of the people don't have flood insurance. The rebuilding effort is going to be particularly challenging because there are going to be a lot of people relying on their own personal assets to rebuild their homes.
HLM: Have these employees' issues affected hospital operations?
Salles: Yes. Most of the hospitals in the flood areas are working short-staffed. The other big impact from a workforce perspective is a lot of schools are closed. Kids are not back in school.
HLM: Do you anticipate a lengthy recover period?
Salles: There's going to be a lasting impact as these employees try to re-establish their lives. That's going to be the challenge. In the immediate aftermath of a disaster, folks were able to keep staff that were at the hospital, as they do in these kinds of disasters, because the ability to get to and from the hospitals in the immediate aftermath was nearly impossible because of road flooding.
They managed through the immediacy. Now comes the long-term issue of how people rebuild their lives and continue to be productive in their jobs and meeting the needs of the community as well.
HLM: Were lessons learned from Hurricane Katrina applied here?
Salles: I think so. We certainly have grown in our emergency preparedness. The immediate issues were handled well. In many respects that is why it wasn't as big of a news story as you might have had after Katrina, where there were a lot of issues.
The immediate disaster was managed very well from a healthcare perspective. Hospitals worked well together. They transferred patients when necessary. All of that worked well. Now we are dealing with the long-term impact on the resources that hospitals rely on to deliver services.
HLM: How do you see the recovery effort playing out in the coming months?
Salles: The big concern is that the employees and the economy are going to be severely impacted as people rebuilt. Certainly we will work not only on getting federal resources, but we are trying to raise money to help individual employees of hospitals. It will be critical to help those folks get back on their feet.
(The Louisiana Hospital Association has established theLouisiana Hospital Employee Assistance Fund for hospital employees who've suffered property losses to their homes. All tax-deductible contributions to the fund will go directly to hospital employees with no administrative costs deducted. To be eligible for assistance, full-time or part-time employees must have experienced flood damage to their residences in a parish that received a disaster declaration from the federal government.)
A report finding no connection between socio-economic status and readmissions rates is being faulted for its lack of granularity by advocates for safety net hospitals.
The ongoing debate about the role of socio-economic status in hospital readmissions was rekindled this month with a report in Health Affairs showing no connection between the two.
"Our paper should not be interpreted to suggest that socioeconomic disparities in health do not exist," Susannah M. Bernheim, MD, MHS, director, Quality Measurement Programs at the Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE), said in an email exchange with HealthLeaders Media.
"Socioeconomic status is an important determinant of health status," she says. "What we have shown is that for quality measures, like the readmission measures that already account for differences in patient illness, socioeconomic indicators do not have a big additional effect on hospital results."
America's Essential Hospitals, an association representing safety net hospitals, took issue with the findings and said it relies upon ZIP code-level data that doesn't provide enough granularity about specific neighborhoods and streets where some safety net patients reside, or what goes on inside those homes.
"We believe the authors of the article have not truly identified the data that can help tease out the variables in geographic areas to fully understand why some neighborhoods are more likely to see readmissions than others," says Beth Feldpush, senior vice president of policy and advocacy at America's Essential Hospitals.
'Vested Interest' in Existing Measures
"They did take a look at demographic variables. The problem is they looked at ZIP codes where patients reside as well as dual eligibility for Medicare and Medicaid. We believe that ZIP code does not get you down to a finely divided enough area to understand the impacts."
Feldpush also noted that the Yale researchers are also "the developers of the readmissions measures themselves. So, you can understand they already have a vested interest in the measures as they are constructed."
Bernheim says CORE research uses U.S. Census data.
"The neighborhood data that we used comes from what is called the American Community Survey, which is collected by the U.S. Census Bureau… which includes information about things such as poverty, income and education levels, or housing within a neighborhood," she says.
She defended the study findings as "quite robust."
"Since we completed this paper, we have continued to study this topic and we consistently get the same results. Adjusting the readmission measures for patient socioeconomic status does not make a difference to hospitals' results even when we use other indicators of patients' socioeconomic status," Bernheim says.
"For instance, we recently presented results showing that adjustment for socioeconomic status measured at the census block group-level also does not affect hospitals' readmission results. That research used an indicator linked to a much smaller neighborhood area than the ZIP code areas used for this paper, but it didn't change the findings. Some people think that results would change if we just had the perfect way to assess socioeconomic status, but that doesn't seem to be true."
Bernheim concedes that people may find it "surprising" that hospitals caring for poorer patients generally perform well on Medicare readmissions measures, and she offered "few things (that) may help explain this finding."
"Most importantly, the readmission measures that Medicare reports are adjusted for patients' level of illness. So if poorer patients are sicker when they arrive at the hospital, the readmission measures already account for those differences among the patients," she says.
"Our study used the measures that are reported by Medicare nationally, which take into account differences in how sick patients are," she says.
"We asked whether socioeconomic status played a major role in hospital readmission rates above and beyond the differences in illness that the measures already take into account, and we found it did not."
Only 20% all hospitals scored a Four-Star rating from the Centers for Medicare & Medicaid Services. One rural hospital CEO talks about getting the message out to patients and their families about the high quality care delivered locally.
Susan Starling, CEO of Mercy Health's Marcum and Wallace Memorial Hospital in Irvine, KY says she's reasonably happy with the Four-Star rating her 25-bed critical access hospital received from the Centers for Medicare & Medicaid Services. That is, until she has to explain to patients why the hospital didn't merit Five Stars.
"I don't think the patients or their families understand the whole rating system," Starling says. "We may perceive Four Stars as really great because there aren't many Five Stars in the U.S., but I don't know that patients understand. They want to know why we're not Five Stars."
Although much of the rankings are based upon patients' perception of their care, Starling says "it's a complicated rating system that is not really set for patients to be able to have a good understanding of what the ratings mean."
"In our market area we do well compared to our competition, but I am not sure how you can market that," she says. "There is opportunity to do that, but I don't know what it is."
Like many hospital leaders, Starling says Marcum and Wallace scores well with the factors it can control.
"Our hospital has high scores in cleanliness. We focus on making it a good patient experience. In a rural hospital we are family and friends caring for family and friends," she says.
Bigger is Not Always Better
"It is a positive environment for our patients where they have good outcomes. They feel comfortable being here. That misnomer of 'bigger is better' is not always true. Our culture is to provide good care to our patients, which is reflected in our rating."
The demerits come, she says, when Marcum and Wallace is hit for factors over which it has little control: For example, payer-mandated discharges that are perceived as premature by patients, and post-discharge care services in a rural region with scarce resources.
"More and more we are trying to get the patients back out into the community, but in rural settings there are often limited options for after-hospital care," Starling says. "We do the best we can, but really patients sometimes aren't ready to go home, even if Medicare or their insurance carriers are demanding that they get back out into the community."
"We don't have a lot of access to home health services and those things such as Meals on Wheels and we have limited physical therapy services out into the community. Those are the challenges that we face in rural that makes it harder to get a better score on post-hospital settings."
To compensate for a lack of resources, Starling says Marcum and Wallace does "everything we can to make it a successful discharge. We work really hard on trying to make sure they have everything they need, the education, the medications, the tools. But again, if that patient goes home and they don't physically feel that they are ready, maybe they don't have the support system at home, then we don't get a good rating, even though we don't have a lot of control over that part of it."
The hospital's attempts to provide resources for a post-discharge care network are hampered by a lack of money.
"Home health pulled out of rural communities because it is not financially feasible for them to be here. Investing in those services is not a good financial move on my part," Starling says.
"The government is not looking at the needs of rural America, and the reimbursement for home health in rural, so the services are just pulling out. The durable medical equipment companies are pulling out of rural as they face these financial challenges. We are the first to get cut."
With the goal of someday achieving a Five-Star rating, Starling says Marcum and Wallace is borrowing strategies from accountable care organizations and forging ahead with new initiatives.
"We are working closely now with a care coordinator in our physician clinics and making sure she understands what is happening with the patients when they are in the hospital, so that when the patient is discharged the coordinator is aware of it," she says.
"We are looking at the patients' different needs and services that they'll need and trying to coordinate that. We just received a federal grant that is going to help us work on medication therapy for the patient and have a pharmacist in some of the clinics help these patients have a better understanding of their medications and monitor them and what the patient understands, what exactly is this medication for."
Using ACO strategies makes sense even if you're not in an ACO, Starling says, because the star ratings are part of larger movement to measure the efficacy of patient-centered and value-based care that hospitals provide.
"Now we are cost based, but that going to change for critical access hospitals," she says. "My goal as the CEO is to try to improve the health of our patients, do the things that we think can help our patients with respect to population health. I am laying the foundation to be prepared for the future, whatever the future is."
"We take our work seriously. We always strive to be a high-performing institution and we measure ourselves against the best healthcare delivery systems we can find, focused on patient and staff satisfaction," says Putnam.
According to CMS, only 102 (2.2%) of the nearly 5,000 rated hospitals earned five stars, and only 934 hospitals, about 20.3% earned four stars, including Margaret Mary Health.
"We've been in the National Rural ACO, which has focused on a lot of quality measures and helped us figure out where we needed to be," Putnam says.
"We are constantly comparing ourselves with others in what we can do better and searching for best practices. That's been pretty active for the last three years, so we didn't anticipate being surprised by the star ratings."
Putnam says that Margaret Mary's membership in the National Rural ACO and in the Suburban Health Organization, a group of eight hospitals in the Indianapolis area, has provided a framework for improvement.
"When you look at all the hard data you have on how you are delivering care, it makes you look at all the data a lot more closely," he says.
"You find out who is doing well and you have a way to find out how to improve your processes because you know they do well and they want to see you do well. This small network of hospitals has shared a lot. A lot of this is an informal process of working together to improve."
In one telling example, Putnam recalls that Margaret Mary clinicians and administrators were baffled by their relatively high pneumonia mortality statistics.
"We were scratching our heads trying to figure out why," he says. "We work with a great infectious diseases physician. We have a lot of histoplasmosis in the area and a lot of COPD, but why is our pneumonia mortality so high?"
"As we got down to it, our processes were good, but our charting of severity of illness was not," he says.
"When we looked at it, our case mix index, our severity of inpatients for all of our Medicare patients, was 1.0. When we had it assessed, we found out that our real severity of illness should have been 1.4 or should have reflected the real disease process going on."
Medicare Pays on Cost of Illness, Not Severity
The problem, it turns out, was that Margaret Mary didn't compare well with general acute care hospitals, because critical access hospitals aren't paid on severity of illness. They're paid on cost.
"By and large we don't document that well," Putnam says. "We're paid on our costs, so how severe the illness is on the Medicare report doesn't get charted. When we looked at the (prospective payment system) hospitals, they are paid on severity of illness, so they track that very carefully and report that very carefully."
"When we figured out what other hospitals were doing and how to do it correctly, all of a sudden our pneumonia scores are accurately reflecting what is going on."
Even though Margaret Mary got a relatively high score, Putnam says he is not satisfied with the rating, neither for his hospital, nor for all hospitals with a mission to improve community health and serve anyone.
Many of CMS's 5-Star hospitals, he says, are niche and specialty hospitals that don't have an open emergency room. "So, they don't take all of the community. They don't take everyone coming through the door," he says.
'Slanted' Metrics
"I don't know all the metrics that go into the rating system, but it is definitely slanted. If you can pick and choose your patients, you do better on the ratings. From the community hospital's perspective, where you are serving and benefitting the whole community, they don't fare as well, yet I know they do an excellent job, especially given their patient population."
It's frustrating, he says, because "ratings only tell a small portion of a story of any hospital. When I look at the ratings, I see some hospitals that are very solid institutions that provide great care and are not ranked very highly. I don't like to see anything that discourages the patients' confidence in their local community hospitals."
