Hospital ratings reflect urban bias, administrators say

Aug. 17—Small-town hospitals may suffer from low rating scores and payment penalties due to urban bias by organizations such as LeapFrog and Centers for Medicare and Medicaid Services, area health care administrators say.

James Berry, CEO of Northeastern Health System, said the general method in which all hospitals are measured is the evaluation of public and discrete data from the federal government.

LeapFrog, a nonprofit watchdog organization, collects data from hospitals and generates a quality-of-care rating.

Berry said LeapFrog has proprietary performance criteria used to assign a letter safety grade.

"LeapFrog performance measurements and letter grades are biased toward large, tertiary hospitals in urban areas," said Berry. "They echo the belief that critical and/or subspecialty care should only occur in large urban hospitals, and all rural communities should transfer complex patients for care because it is 'appropriate and safe'."

NHS received a "D" grade from Leapfrog Hospital Safety Grade in spring 2023. According to the report, under the category "Practices to Prevent Errors," all six subcategories were rated as "Hospital Performs Worse Than Average." The same was reported on the subcategories under "Doctors, Nurses & Hospital Staff."

Hospital Compare, formed to do the ratings for CMS, grades the services given by hospitals certified by Medicare/Medicaid. Penalties were established by the federal government under the Affordable Care Act, enacted in March 2010.

Under programs set up by the ACA, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. CMS imposes penalties from 1% and up to no more than 3%.

According to Brian Woodliff, NHS chief executive and strategy officer, said disincentives for Medicare range from 0% to 3%, based on CMS' campaign to reduce the frequency of hospital readmissions by applying financial disincentives.

"Ninety-three percent of all hospitals have received a reduction in their reimbursement since the program began in 2013," said Woodliff. "NHS received one-eleventh of 1% reduction in 2022."

NHS received 2 stars for the overall category from Hospital Compare, and also for patient survey rating. This information is located on www.medicare.gov.

"Medicare doesn't typically pay 100% of medical costs for the beneficiary," said Woodliff. "Generally speaking, CMS reimbursement is about 35% of the charges from the providers. The new Medicare advantage plans pay providers even less."

NHS scored better than other competitors such as Massachusetts General Hospital, a teaching hospital for Harvard University, and competitors in Tulsa, said Woodliff.

"Northeastern Health System views the campaign evaluation as one of many quality indicators," said Woodliff.

Other rural hospitals in the area are also subjected to Hospital Compare's low ratings. Wagoner Community Hospital garnered 2 stars, and Sequoyah County-City of Sallisaw Hospital Authority earned 3 stars overall.

Three rural hospitals earned a much higher rating: Memorial Hospital in Stilwell, with a 5 star rating; and Hillcrest Hospital in Pryor and Claremore both received 4 stars overall.

The overall star rating is based on how well a hospital performs across different areas. The five measure groups include: mortality, safety of care, readmission, patient experience, and effectiveness of care.

Patient survey ratings measure patients' experiences during a hospital stay. Recently discharged patients are asked about their experience with staff communication, responsiveness, and cleanliness and quietness of the hospital.

Subcategories under the doctors, nurses and staff category, are: effective leadership to prevent errors, enough qualified nurses, specially trained doctors to care for ICU patients, communication with doctors and nurses, and responsiveness of hospital staff.

Berry explained the biases he says are held by LeapFrog.

"LeapFrog's standard measure for an effective Intensive Care Unit, equates appropriate treatment as only under the supervision of a critical care specialty physician," said Berry. "All day, every day — otherwise [LeapFrog rates] the care provided is substandard hospital care for critical patients."

NHS employs only one pulmonologist/critical care specialist in Tahlequah, Dr. Creticus P. Marak, who provides 10 to 12 shifts of 12 hours per month in the ICU, due to physician scarcity.

Another consideration by LeapFrog is the percentage of registered nurses with bachelor's degrees in nursing, and surgical competence.

"My 30 years in health care have taught me that it's not the education that counts, but the passion to help 'people get better'," said Berry. "Fewer people in rural areas have advanced education, including RNs. NHS disagrees with LeapFrog's philosophical position but has no outlet for discussion."

All surgeons at NHS are board-certified, said Berry. LeapFrog establishes procedural competence based upon the number of procedures completed per year.

"This is LeapFrog's urban bias," said Berry. "It has a medical social media bully pulpit. They publish your grade. There is no option for appeal or room for discussion. Like a Google opinion, the power resides with the evaluator."

Berry believes NHS will have a better LeapFrog rating for 2024.

What's next

The second article, which will publish in the Aug. 23 edition, will focus on W.W. Hastings Hospital and other nearby hospitals.