bb Albert Provocateur: April 2009

Albert Provocateur

Sunday, April 19, 2009

Making the Grade

For those of us who are baby-boomers and old enough to remember, taking a bad report card home engendered a great deal of fear and trepidation, during what seemed an endless walk or school bus ride home. Perhaps that is the way hospital CEOs currently look at the issue of transparency and public disclosure, as they closely guard their respective institutions’ financial and clinical secrets, and damn or withhold any revelation destined to transform stockholders into what amounts to angry parents.
Healthcare consumers, the U.S. federal government, and third-party payers, however, demand the highest standard of care from our nation’s hospitals, as well as reliable performance measures to assure quality. Furthermore, such measures must be applicable to all hospitals, whether they reside in the high-tier or low-tier category. There is much evidence to support the contention that hospital report cards, based on objective performance measures, improve the overall healthcare of patients.
The Hospital Quality Alliance (HQA), based on provisions in the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and instituted by the U.S. Department of Health and Human Services (HHS), was, indeed, initiated precisely to that end. By collecting data on key measures of hospitals’ management and quality of care (for example, the care provided, the resources consumed, the total costs of care, and the resulting outcomes), the HQA can tabulate report cards to motivate change and hopefully improve overall patient healthcare. Also, the recently proposed Deficit Reduction Act (DRA) of 2005, by instituting financial incentives to entice our nation’s hospitals to “make the grade” by adhering to established measures of performance, and expanding them when necessary, serves as an additional built-in safeguard to our nation’s health.
High performance scores on HQA performance indicators have been associated with up to 15 percent reductions in the odds of death for common clinical conditions such as acute myocardial infarction, congestive heart failure, and pneumonia. So, the initial results are in, and perhaps only a bit of tweaking and several more performance indicators are required before hospital report cards become a diffuse functioning reality.
Who would have ever thought that the long bus ride home would be good for one’s health!

© 2009, Albert M. Balesh, M.D. All rights reserved.

posted by Dr. Al at 4/19/2009 01:27:00 PM | 0 comments

Sunday, April 12, 2009

Trojan Horse: What Lies within a Hospital's Report Card could Spell Trouble

No one likes examinations, let alone report cards, but the stakes are just too high to let our nation’s hospitals continue with business as usual, with no form of grading system in place to hold them accountable. U.S. public health agencies and the federal government must retain the right to impose guidelines, parameters, or benchmarks, whatever one wishes to call them, on hospitals in order to ensure a standard of care that lowers in-hospital mortality rates and guarantees citizens (and illegal immigrants, too) the same level of care, whether they are admitted to high-tier or low-tier hospitals. The petty bickering of hospital CEOs must be put aside, and objective transparency must win the day, both in terms of financial ledgers and healthcare morbidity and mortality data. Without an objective set of rules and regulations to go by, if you will, and grades (based on accurate scientific data) to indicate performance and compliance, measurement of our nation’s hospitals’ standard of care and delivery will be based on quackery, hearsay, sensationalism, and the subjective. That is exactly what is occurring at this precise moment. But, wait just one minute! Perhaps we are being a bit too hasty here. Human nature being what it is, perhaps we will never truly reach our goal of objective measurement of hospital quality of care. Perhaps a hospital’s closely guarded secrets, whether they be financial or clinical, run countercurrent to the dictates of hospital quality assurance, and must, indeed, remain in the private domain. Perhaps our energies should be directed at what is realistic and what we can actually do, and that is develop subjective criteria that parallel and confirm the results of objective measurement of hospital performance.
The latter, in fact, is just what has occurred. As consumers, the U.S. federal government, and third-party payers continue to not only demand the highest standard of care in our nation’s hospitals, but also reliable and valid performance measures to guarantee that standard, the subjective perceptions of hospital executives have been compared to objective criteria used. Lo and behold, what has come to light is surprising, and that is that subjective perceptions of hospital CEOs on the organizational performance of their institutions, with particular attention being paid to subjective perceptions of financial measures such as return on total assets (ROA) and operating margin, correlate strongly with how those institutions actually perform. So, perhaps there is, indeed, some room, after all, for the subjective in the accurate assessment of a hospital’s performance and standard of care.
But that can’t be it in a nutshell, and we cannot rely solely on the subjective. We must look closer, for a cursory, subjective look at our nation’s healthcare system and its protective arsenal of hospitals is tantamount to a Trojan stamp of approval, with subsequent dire consequences when what lurks within translates into the higher mortality rates seen only by those with specialized training to view the writing on the wall. Hospital quality assurance must be based on a standardized set of objective criteria or measures, applicable to all hospitals. A step in the right direction has been the Hospital Quality Alliance (HQA), based on provisions in the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and instituted by the U.S. Department of Health and Human Services (HHS), which has collected and continues to collect data on key measures of hospitals’ management. Not only that, but the recently proposed Deficit Reduction Act (DRA) of 2005 has also added extra “punch,” and provided the financial incentives for our nation’s hospitals to adhere to established measures of performance, to report compliance with those measures to the HHS, and to expand those measures when the HHS Secretary deems it necessary, to safeguard the nation’s health.
To date, the HQA has developed ten performance indicators for three of the most common maladies seen in a general hospital environment, namely acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Without going into specific details, summary scores, i.e., performance scores, were calculated per each of 3,720 U.S hospitals surveyed by the HQA on the basis of the sum total of the results reported for each of the ten performance indicators. It was found that high performance scores on the ten HQA performance indicators was associated with a 7-15 percent reduction in the odds of death for each of the three clinical conditions listed above. So, higher performance on the HQA objective indicators correlated nicely with lower hospital mortality rates for the three clinical conditions.
Perhaps there is hope, after all, that hospital mortality rates can be lowered without the divulging of “trade secrets” by hospital CEOs. If that is the case, then there is little need to expose what lies within a hospital’s “Trojan horse.”

© 2009, Albert M. Balesh, M.D. All rights reserved.

posted by Dr. Al at 4/12/2009 07:39:00 PM | 0 comments