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Ratings for hospitals, doctors, surgeons, home health agencies, nursing homes

September 6, 2015

Tags: rating health care, rating hospitals, rating doctors, rating home health care agencies

by Pat McNees. Updated 12-13-17.
I've listed here various "scorecards" and ratings for different aspects of the U.S. health care system, because they're a step toward helping consumers figure out how to choose healthcare providers, services, and institutions. The problem is, different groups choose different ways of evaluating doctors and hospitals and to the extent that some use some punishment measures to protect consumers (measures which might work against ratings for doctors or hospitals that try to provide more and more sophisticated services, for example), and that some measures seem to conflict, this must all be taken with a grain of salt. Also, some ranking systems don't rank all hospitals in a system-- rank only those that fit criteria that group (e.g., Leapfrog) chose to rank. Be sure to take a look at the bigger picture because the ranking organization may not be. There is also at least one paradox in ranking systems: Sometimes the better academic hospitals get worse rankings because they're better at reporting adverse events, they may treat more difficult cases, and they often treat patients of lower socioeconomic status, whose health may be worse to begin with.
Ratings are an important step toward making health care more transparent for consumers. Scroll to the bottom for some fairly recent criticisms and Norman Bauman's analysis of problems with various rating systems.

Surgeon Scorecard. ProPublica's informal website shows death and complication rates in eight types of surgery, showing results on all surgeons, good or bad. with 20 or more surgeries in a category. See USA Today story 'Surgeon scorecard' measures docs by complications.But also, see Kevin MD's criticism of the site The ProPublica Surgeon Scorecard: When journalists become scientists (10-9-15) and the Rand Corp.'s A Methodological Critique of the ProPublica Surgeon Scorecard Writes Kevin MD: "With the Surgeon Scorecard, ProPublica acted as judge and jury; they defined the measure, deemed it valid, and declared which surgeons were low quality....While ProPublica says its work was “guided by experts,” that review was informal."

Globe1234.info Paul Burke summarizes info available elsewhere on ratings of Doctors and of hospitals, but that's just a start. He has summarized information on procedures, things to eat, and so on--spend time exploring this very helpful site.

Paul Burke compared methods for the Checkbook and ProPublica rating systems (Globe1234). Globe1234.com provides all kinds of data a patient might/should want to have. For example:
---Hospital Quality, and Incentives at http://www.globe1234.info/medicare/quality
---Doctors' Quality and Incentives at http://www.globe1234.info/medicare/doctors
"This site does not recommend doctors, hospitals or anyone. It summarizes information, mostly from Medicare, so you can decide."

Data on Hospitals (all the data you are likely to find, gathered by Paul Burke) For example, look up bond disclosures on EMMA (Electronic Municipal Market Access), which has PDF copies of operating expense and audited financial statements for each hospital.

SurgeonRatings.org (Consumers' Checkbook's new website lists surgeons Checkbook has identified as having better–than–average outcomes -- covers 15 types of surgery, but only lists surgeons significantly above average on 90-day mortality, readmissions, and same-stay complications.

Open Payments Data (OpenPaymentsData.CMS.gov) Do you wonder if your doctor is getting a commission or other benefit for recommending expensive drugs or devices? Find out. When a drug or device company gives a physician or a teaching hospital- stocks, money for research, gifts, speaking fees, meals and other payments, The Open Payments Program is required to collect information about those payments and share it with the public. Read ProPublica's report Drug and Device Makers Find Receptive Audience at For-profit, Southern Hospitals (Charles Ornstein and Ryann Grochowski Jones, Pro Publica, 6-29-16) A ProPublica analysis shows that where a hospital is located and who owns it make a big difference in what share of its doctors take industry payments. This is part of an ongoing investigation, Dollars for Doctors: How Industry Money Reaches Physicians (ProPublica tracking the financial ties between doctors and medical companies). See also Doctors received $6.5 billion from drug and device companies in 2015 (Carolyn Y. Johnson, WaPo, 6-30-16)
Buying drugs and procedures smartly, cheaply, safely (Pat McNees's roundup of price comparison tools)
Doctors' Quality and Incentives (Globe1234.info)--links under several categories: Doctors Reviewed by Doctors, Doctors Reviewed by Statistics, Doctors Reviewed by Patients, Patterns of Complaints by Patients, Referral Service: Grand Rounds, No Privacy on the Web: Tracking Your Search for Doctors

Consumers' Checkbook advice on and lists of top-rated doctors, with LOTS of explanations. $Subscription required (but check your library). Covers ratings from patients for these areas: Boston, Chicago, Philadelphia, San Francisco-Oakland-San Jose, Seattle-Tacoma, Twin Cities, and Washington, DC, for both primary care physicians and many types of specialists. (I subscribe and find Checkbook very helpful.)

US Rumor and Hospital Report (Paul Levy criticizing the annual hospital ranking prepared by US News and World Report, Not Running a Hospital, 8-3-11) "US News needs to stop relying on unsupported and unsupportable reputation, often influenced by anecdote, personal relationships and self-serving public appearances, and work on real -- and more recent -- data.... it is time to acknowledge that this ranking offers very little in the way of valuable information. It is mainly a vehicle for advertisements from the pharmaceutical industry, who know that this issue of the magazine gets a lot of attention and high circulation."

U.S. News Best Hospitals (U.S. News & World Report). Also lists top three hospitals in each of sixteen specialties (cancer, cardiology & heart surgery, diabetes & endocrinology, ear, nose & throat, gastroenterology & GI surgery, geriatrics, gynecology, nephrology, neurology & neurosurgery, ophthalmology, orthopedics, psychiatry, pulmonology, rehabilitation, rheumatology, and urology).

Hospital Compare (Medicare)
---Kevin MD writes: "While the federal government has steadily expanded the number of publicly available measures on its Hospital Compare website, it still falls short of what many patients, payers, and providers would like. This is particularly true in the realm of outcomes such as infections and mortality rates, and in provider-level ratings."
---What journalists should know about hospital ratings (Liz Seegert, Covering Health, Association of Health Care Journalists, 6-24-16) "Journalists should take hospital ratings with a healthy dose of skepticism, according to experts at a recent AHCJ New York chapter event. Simply looking at an institution’s overall rating is just the start. Reporting that without understanding what’s being rated and how ';success' is measured does a disservice to your audience."
---Only 251 U.S. hospitals receive 5-star rating on patient satisfaction (Sabriya Rice, Modern Healthcare, 4-16-15)
---CMS gives 215 hospitals 'five stars' for patient experience. See how yours fared on our map. (Advisory Board, 8-15-17) CMS recently updated its Hospital Compare website with new Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) summary star ratings for 3,504 hospitals.
Medicare Prepares To Go Forward With New Hospital Quality Ratings (Jordan Rau, Kaiser Health News, 7-22-16) "Despite objections from Congress and the hospital industry, the Obama administration said it will soon publish star ratings summing up the quality of 3,662 hospitals. Nearly half will be rated as average, and hospitals that serve the poor will not score as well overall as will other hospitals...The government says the ratings, which will award between one and five stars to each hospital, will be more useful to consumers than its current mishmash of more than 100 individual metrics."

Hospital Safety Score. See State Rankings (Maryland not rated).

The Leap Frog Group Promotes improvements in the safety of health care by giving consumers data to make more informed hospital choices. Says one health care journalist, "One caveat: If your hospital is good at finding and reporting complications, they look bad, even if they are doing everything right."

Doctors & Hospitals (Consumer Reports)

Cups half full and half empty (Paul Levy, Not Running a Hospital, 7-24-15)

The Honor Roll of Best Hospitals (Avery Comoraw, U.S. News & World Report, 7-15-15)
Go to the website to see which departments got the highest rankings at each hospital
1. Massachusetts General Hospital (Boston)
2. Mayo Clinic (Rochester, Minnesota)
3. Johns Hopkins Hospital (tie, Baltimore)
3. UCLA Medical Center (tie, Los Angeles)
5. Cleveland Clinic
6. Brigham and Women’s Hospital (Boston)
7. New York-Presbyterian University Hospital of Columbia and Cornell
8. UCSF Medical Center (San Francisco)
9. Hospitals of the University of Pennsylvania-Penn Presbyterian (Philadelphia)
10. Barnes-Jewish Hospital/Washington University (St. Louis)
11. Northwestern Memorial Hospital (Chicago)
12. NYU Langone Medical Center (New York)
13. UPMC-University of Pittsburgh Medical Center (Pittsburgh)
14. Duke University Hospital (Durham, North Carolina)
15. Stanford Health Care-Stanford Hospital (Stanford, California)

Best Hospitals for Adult Cancer (U.S. News & World Report)
Best Hospitals for Adult Cardiology & Heart Surgery (U.S. News & World Report)
Best Children's Hospitals 2015-16 (U.S. News & World Report)
Best Hospitals for Adult Neurology & Neurosurgery

Yale-New Haven Hospital U.S. News ranking remains high but dips slightly (Ed Stannard, New Haven Register, 7-21-15) 'In addition to the complex care procedures, U.S. News rated the nation’s hospitals in five “common care” procedures that most hospitals perform, whether they are trauma centers like Yale-New Haven or less specialized hospitals. While it ranks high in specialties such as diabetes and gynecology, Yale-New Haven is rated average in heart bypass, hip replacement and heart failure and below average in knee replacement and chronic obstructive pulmonary disease. “Yale did not distinguish itself,” Harder said. “It was average or below average in each of those areas.”

Health Grades (ratings for physicians)

Dr Foster goes to America (Owen Dyer, BMJ, 7-22-15) A plethora of hospital rating systems has caused confusion in the US but now, with the help of healthcare analyst Dr Foster, that may be changing. (You may sign up for a two-week free trial subscription to BMI)

SurveyUSA News Poll on Health Care Data (showing public opinion on various aspects of the health care debate, by gender, race, party affiliation, ideology, level of college education, income, region, and age)

Nursing Home Compare (Medicare's site, offering information about every Medicare and Medicaid-certified nursing home in the country. Paula Span, in the following article, writes that the system does not pay enough attention to patients' complaints: The Fault in Our Stars (Paula Span, New Old Age, NY Times, 7-8-14).
What quality measures can tell us about nursing home ratings (Liz Seegert, Covering Health, AHCJ, 7-27-16). "Nursing home star ratings are misleading and disingenuous, according to a recent analysis comparing ratings with quality measures alone. More than a thousand nursing homes nationally with high overall ratings had only one or two stars in quality measures, which could point to some serious health implications for residents."

Home Health Agency Ratings By State (Kaiser Health News analysis of data from the Centers for Medicare and Medicaid Services)

HospitalInspections.org (website/database run by the Association of Health Care Journalists, AHCJ, updated July 2017), which aims to make federal hospital inspection reports easier to access, search and analyze. Includes details about deficiencies cited during complaint inspections at acute-care, critical access, or psychiatric hospitals throughout the United States since Jan. 1, 2011. Does not include results of routine inspections or those of long-term care hospitals. See A Q&A with CMS: Getting up to speed on inspection reports, in which the Centers for Medicare and Medicaid Services answers questions about the inspection process and the 2567 forms used to complete the inspections. Other sidebars include How to read inspection reports, Sample inspection report, Points to keep in mind about this data, States that put hospital inspection reports online.

Nursing Home Inspect: Find Nursing Home Problems in Your State (Charles Ornstein and Lena Groeger, ProPublica, Journalism in the Public Interest). Use this tool to compare nursing homes in a state based on the deficiencies cited by regulators and the penalties imposed in the past three years. See also What’s New In Nursing Home Inspect. Paula Span wrote about this site in Shopping for a Nursing Home? There’s a Tool for That (NY Times, 9-6-12)

Why Not the Best? (WNTB) Select and compare hospitals by region, health system, size, ownership, or type. Explore performance variation among different hospital groupings - by size, ownership, or type. Compare regions: Explore aggregate performance and population health in U.S. counties, hospital referral regions, and states. These data are Medicare/Medicaid discharges only. p

What journalists should know about hospital ratings (Liz Seegert, Covering Health, Association of Health Care Journalists, 6-24-16) "Journalists should take hospital ratings with a healthy dose of skepticism, according to experts at a recent AHCJ New York chapter event. Simply looking at an institution’s overall rating is just the start. Reporting that without understanding what’s being rated and how ';success' is measured does a disservice to your audience."

and
Concerns about using the Patient Safety Indicator-90 composite in pay-for-performance programs (Rajaram et al. JAMA, 3 March 2015, 313(9):897)
Norman Bauman writes, on the AHCJ listserv (I quote by permission), "A big problem is that CMS is using these ratings to financially reward or punish hospitals for supposed good or bad quality, when these measurements haven't been scientifically validated and there's good evidence that they're not only invalid but contrary indicators. They financially penalize good hospitals. Rajaram criticized the [Patient Safety Indicator] program in JAMA and recommended against it. One problem was risk adjustment (some of the "clinical adverse outcomes," like serosal tear, are inconsequential). Another problem was surveillance bias. "Hospitals with higher VTE prophylaxis rates paradoxically had worse risk-adjusted performance on the PSI-12 VTE outcomes measure." So "PSI-90 may unfairly penalize many hospitals that have a high VTE event rate due to increases in vigilance in detection, not poor quality of care."
Norman again: "The only U.S. system I know that has been able to measure outcomes of different doctors and institutions accurately, use them to manage and improve
quality, and publish their results, is the Veterans Health Administration."
Note that the CMS ratings will sometimes direct you to hospitals with *worse* outcomes. (Critical point: the difference between process measures and outcomes measures.)Sometimes, hospitals with worse ratings had better outcomes. Rajaram explains why. Hospitals that do a better job of measuring secondary outcomes like deep vein thrombosis are going to find more DVT and look worse.

More generally, continues Bauman, "Among hospitals participating in the HAC Reduction Program, hospitals that were penalized more frequently had more quality accreditations, offered advanced services, were major teaching institutions, and had better performance on other process and outcome measures." See Hospital Characteristics Associated With Penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program (Ravi Rajaram et al., JAMA, 7-28-15, Vol. 314, No. 4).

What Makes A Good Surgeon? What Makes A Good Hospital? (Norman Bauman, Veins1.com, 9-10-07). Basically you get the best results in a hospital that does a lot of a particular procedure, and at that hospital, you get the best results with a surgeon who specializes in that procedure.

Norman Bauman continues, another day: "The big problem, I think, is that there are several different ways of rating hospitals, and they all come up with contradictory recommendations. If they can't get consistent results, something is wrong. The ratings can't all be valid. You've converted the problem of finding the best hospital to the problem of finding the best rating system.

"Sometimes the hospital ratings correlate *negatively* with mortality rates. In other words, you're more likely to die in a hospital with a good rating than in a hospital with a poor rating, according to some rating schemes.
"I've cited articles on this list that explain why:
(1) Hospitals that are more careful in diagnosing adverse events, like deep vein thrombosis, are going to look worse than hospitals that have more DVT but don't diagnose it.
(2) Many of the rating systems deliberately don't take patient poverty into account. So patients can't afford prescribed medication, they can't afford transportation to the hospital for followup treatment, and they have worse outcomes, but that's not under the hospital's control.
(3) Some hospitals, particularly the specialist hospitals, take more difficult cases, and their patients are more likely to have bad outcomes. For example, if a patient needs surgery for an abdominal aortic aneurysm, the main factors in survival are patients, age, lung function, heart function, and kidney function. The doctor has no control over that.
"Let's talk turkey. There are political reasons why people are putting so much effort into hospital rating systems for consumers is that we need one, in order to have a free-market health care system, rather than a single payer or other national system that virtually every other developed country in the world has. Kenneth Arrow, the Nobel laureate economist, said that a free market in health care was impossible because there is an imbalance of knowledge between doctors and patients:
Liberals Are Wrong: Free Market Health Care Is Possible ((Megan McCardle, Atlantic, 3-18-12)
Why markets can’t cure healthcare (Paul Krugman, The Conscience of a Liberal, NY Times, 7-25-09)
"Patients can't possibly know enough to evaluate health care. Only about 10% or 15% of patients have enough health literacy to follow basic patient information sheets. If you're pushing a free-market health care system, you have to come up with a way of proving Arrow wrong and giving patients a way to be "wise consumers." These rating systems are supposed to make choosing a doctor as easy as choosing a refrigerator from Consumer Reports. They've never worked. The biggest problem is that they can't answer outcomes questions, "How likely am I to die from this surgery?" That's because most of them don't measure outcomes, they measure secondary indicators or processes like how many DVT cases the hospital reports.

"Ironically, when I did the research, the hospitals with the best outcomes research and data were the ones in the Veterans Affairs system, which is an example of what a good American single payer system could look like. They've done studies for example on surgeries, like appendicitis or colon cancer, in all hospitals throughout their system, and measured the outcomes, including mortality, and variations. They find the places with poor outcomes and correct them. They have the great advantage of a good electronic health record that can get consistent data throughout their system, and generally better patient data. In the private sector, they have to make do with electronic health records that were designed originally for billing, and modified for quality control. A good story would be to compare the outcomes and quality at the local VA hospitals with the private hospitals, although they might be spooked from the attacks."

In addition, most comparison sites use Medicare death rates, "Medicare death rates, which exclude anyone who's been on hospice at any time in the past year, up through the first day of the hospital stay," says Paul Burke. "Hospice is wonderful, but people on hospice don't go to hospital much, so hospice deaths after a hospital stay would typically mean they were in hospice earlier in the year and left it, or they signed up for hospice on the first day of the hospital stay. In any case someone eligible for hospice in the past year has fragile health, and should be counted in hospital mortality."

The Problem With Satisfied Patients (Alexandra Robbins, The Atlantic, 4-17-15) A misguided attempt to improve healthcare has led some hospitals to focus on making people happy, rather than making them well.
Why Markets Can't Cure Health Care (Paul Krugman, NY Times, 7-25-09)

MEDICARE COMPARE SEARCH PAGES
Dialysis Compare
Home Health Compare
Hospital Compare
Inpatient Rehabilitation Facility Compare
Long-Term Care Hospital Compare
Medicare Plan Finder
Nursing Home Compare
Physician Compare

"Hospital Choice May Be a Matter of Life or Death", aka Go to the Wrong Hospital and You’re 3 Times More Likely to Die. (Reed Abelson, NY Times, Business Day, 12-14-16) "While consumers can use tools like Medicare’s Hospital Compare, which offers general quality information about individual hospitals, the data are very limited, Dr. Rosenberg said. Many quality measures rely on reporting about whether the hospital gives patients an antibiotic, not whether they develop an infection, and they do not distinguish among different diseases. A hospital that is a top performer in heart surgery, for example, may be a poor place to choose to get a knee replacement. The authors say patients need such information. 'This paper raises the question of why don’t we have broader outcomes measurement and transparency around performance,' said Dr. Justin B. Dimick, one of the authors and a surgeon and researcher at the University of Michigan." Atul Gawande (one of the co-authors of the study Abelson describes (link below) points to two areas where information is publicly available: heart surgery by the Society of Thoracic Surgeons and cystic fibrosis. In those two areas, patients have the ability to make better-informed decisions and hospitals can use the data to improve their care.
Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment (Barry L. Rosenberg, Joshua A. Kellar, Anna Labno, et al., PLoS One, 12-14-16)
The Burgeoning “Yelpification” Of Health Care: Foundations Help Consumers Hold A Scale and a Mirror to the Health Care System (Paul Howard, Yevgeniy Feyman, and Amy Shefrin, Health Affairs, 5-25-17). The following links come from that piece.
Yelp Reviews Of Hospital Care Can Supplement and Inform Traditional Surveys of the Patient Experience of Care (Benjamin L. Ranard et al., Health Affairs, April 2016)
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
National Hospital Ratings Systems Share Few Common Scores And May Generate Confusion Instead Of Clarity
National Hospital Ratings Systems Share Few Common Scores And May Generate Confusion Instead Of Clarity (J. Matthew Austin, et al., Health Affairs, March 2015)
Still Searching: How People Use Health Care Price Information in the United States, New York State, Florida, Texas and New Hampshire (PDF, Public Agenda, April 2017)
Consumer Perspectives on Health Care Decision-Making Quality, Cost and Access to Information (Linda Weiss, PhD, Maya Scherer, MPH, Anthony Shih, The New York Academy of Medicine)
Principles for Making Health Care Measurement Patient-Centered (American Institutes for Research, April 18, 2017)
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Comments

  1. July 22, 2016 11:40 PM EDT
    Medicare Prepares To Go Forward With New Hospital Quality Ratings (Jordan Rau, Kaiser Health News, 7-22-16) "Despite objections from Congress and the hospital industry, the Obama administration said it will soon publish star ratings summing up the quality of 3,662 hospitals. Nearly half will be rated as average, and hospitals that serve the poor will not score as well overall as will other hospitals...The government says the ratings, which will award between one and five stars to each hospital, will be more useful to consumers than its current mishmash of more than 100 individual metrics."
    - Pat McNees
  2. August 17, 2016 4:40 PM EDT
    Research on Readmissions, Death Rates, Minorities (Globe1234.com, 5-16-13) Among points made (from various reports):
    • "safety-net hospitals were more likely than other hospitals to be penalized under the... Hospital Readmissions Reduction Program...
    • Dr Ashish Jha, of Harvard's School of Public Health, told PBS, "If you look at, for instance, the U.S. News [and World Report] publishes its list of top 50 hospitals. Those hospitals tend to have very low infection rates, very low mortality rates, very low death rates. Guess what? They tend to have very high readmission rates, because they do such a good job of keeping their patients alive that many of them are readmitted."
    • Dr. Sunil Kripalani, of Vanderbilt University Medical Center told Fox News, "Among patients with heart failure, hospitals that have higher readmission rates actually have lower mortality rates. So, which would we rather have -- a hospital readmission or a death?" "We found that large hospitals, teaching hospitals, and SNHs [safety net hospitals] are more likely to receive payment cuts under the HRRP [readmissions penalties]. It is unclear exactly why these hospitals have higher readmission rates than their smaller, nonteaching, non-SNH counterparts, but prior research suggests that differences between hospitals are likely related to both case mix (medical complexity) and socioeconomic mix of the patient population.2-3 There is less evidence that differences in readmissions are related to measured hospital quality.6" (2013) Journal of the American Medical Association. 2013 Jan 23;309(4):342-3
    - PM
  3. August 17, 2016 4:49 PM EDT
    Readmissions, Observation, and Improving Hospital Care (blog of Ashish Jha, An Ounce of Evidence/Health Policy). Various blog entries.
    Ashish Jha — "physician, health policy researcher, and advocate for the notion that an ounce of data is worth a thousand pounds of opinion." See, for example, Is the Readmissions Penalty Off Base? "The Leapfrog Group will soon be putting out another report of patient safety in U.S. hospitals (I’m on their advisory panel). It will provide letter grades on the state of safety of every hospital. The grading system is not perfect—primarily because hospitals are not required to report their rates of medical errors. Yet Leapfrog soldiers on, trying to make their best assessment. I wish Medicare would make patient safety half as much of a priority as reducing readmissions. Oh, and by the way? Reducing medical errors can likely save us a lot more money than reducing readmissions—so even if we do it for the money, that should be our target."
    - PM
  4. December 15, 2017 5:15 PM EST
    5 must-have upgrades for the consumer-focused health system (Advisory Board, preview of restricted content). The five upgrades:
    (1) Frictionless transactions (84% of consumers say that price estimates have an impact on choosing a provider).
    (2) Multimodel access network (6 of the top 10 decision drivers are related to access and convenience, when choosing a primary care physician; 42% of consumers report “short travel distance” as a top-three driver when choosing a specialty care provider.
    (3) High-Reliability Production Model: Service and clinical quality are increasingly important.
    (4) Competitive Price Point: Patients will go to great lengths for lowest price.
    (5) Loyalty reward program. From the moment they first contact the system, patients should experience the customization and personalization possible in an integrated system. But 47% of consumers are not “highly loyal” to their current PCP and may switch providers in the next 12 months.
    - PM