Q&A With Gregory Downing, DO, Ph.D., Chief Clinical Officer of Cureatr
In late July, the Centers for Medicare & Medicaid Services (CMS) updated its hospital quality star ratings. In this interview, Gregory Downing, DO, Ph.D., Chief Clinical Officer of Cureatr, discusses the star rating program, key takeaways from this most recent update, the significance and potential causes of declines in star ratings, and ways hospitals can help improve their star ratings.
Q: What is the significance of the hospital's quality star rating program?
Gregory Downing: The program is used to evaluate the overall quality of hospitals. This year's rankings have more than 5,000 hospitals measured against five distinct categories of care. There are approximately 47 quality measures and survey results integrated into the star rating system, which uses a ranking system of 1 star to 5 stars. More stars indicate higher quality: 1 star is poor; 5 stars is top notch.
The five categories that are generally equally weighted are mortality, the safety of care, readmissions, patient experience, and the timeliness and effectiveness of care. Patient experience is determined in part through the administration of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) patient surveys concerning their hospital experiences. Timeliness and effectiveness of care look at matters like how long it takes for a patient to schedule an appointment, be admitted into the emergency department, and other care experiences.
The information gathered by CMS for the quality star rating program is used in many ways. There are public-facing ratings reflected on websites like CMS's Care Compare. You can go onto this website and research and compare the performance of different hospitals. These are intended to help guide consumers in making choices about the hospitals in their community or a corollary health plan, such as a Medicare Part D plan. Providers also use this information as part of their professional and care research. For 20-plus years, CMS has been increasing the amount of quality rating information it provides.
There are cost implications to star rating hospitals must take into account. Hospitals can see their revenue reduced due to hospitalizations that occur. Take readmissions. If a hospital experiences a significant increase in readmissions year over year, and generally the star ratings look at three-year time blocks, then CMS could decrease a percentage of its payment to the hospital for subsequent years.
There are other important financial components hospitals are subject to and that's through the Hospital Inpatient Quality Reporting Program. Hospitals can experience fee adjustments due to how they performed year over year, such as last year to this year. Those adjustments are reflected in value-based purchasing programs where clinical outcomes and community engagement, safety and efficacy, and cost-reduction factors are also used. In this program, hospitals are gauged from the standpoint of achievement and improvements.
Let's take a closer look at the 2022 quality star rating results, specifically looking at those hospitals which saw a decline. It's important to understand that there's a fair amount of flux in the star ratings that occur each year. That's the case for this year as well. As many hospitals and health systems have experienced COVID-19-related challenges, there's been adjustments made every year since 2019 to these reporting measures to accommodate for the atypical experiences in hospitals and increased admissions or mortality related to the coronavirus.
This year, there were:
- 127 hospitals that went from 5 to 4 stars;
- 6 hospitals that went from a 5 to a 3;
- 219 that went from a 4 to a 3;
- 15 that went from a 4 to a 2.
For those hospitals with more than one-star rating change, that's a pretty dramatic shift and there are probably multiple reasons for such a change. The published, public-facing data doesn't allow us to go into a particular hospital's rating and see which measures likely influenced the change. Hospitals know their own performance, but we in the public usually do not.
Hospitals doing well tend to promote their status and star ratings, and rightfully so. They do a lot of work to strive to achieve better star ratings. The categories and their measures represent significant areas for a hospital. You can change some components of the star ratings relatively quickly, but it takes a pretty substantial effort overall to move up a full point or two. That is likely to require a multi-year effort. The overall impact of some individual, meaningful interventions can take significant time to implement in some cases.
Q: You noted that more than 350 hospitals lost their 5-star and 4-star positions in this latest update. Why are such declines significant for these organizations?
GD: It goes back to the two factors I spoke about earlier. From the consumer standpoint, purchasers of healthcare look at these ratings to help them determine whether they are getting the best quality care and the best services they can for their dollar.
The other factor is obviously the economic impact. During this time, we're in where we're seeing a sort of post-COVID-19 reallocation of resources and reduction of federal funding for COVID-19, and there are a lot of conversations happening about hospital revenue. The reduction of Medicare dollars can have quite a significant impact on a hospital. One percent or two percent decline because of readmissions can be a substantial factor in a hospital's budget.
Q: While you indicated we do not know what exactly contributes to star rating declines, what do you believe are likely some of the most significant factors?
GD: Changes in mortality rate can be a big factor. Readmissions are a big one that tends to greatly affect a hospital's star ratings. Changes to performance concerning safety measures are a third factor that likely pushed ratings down — or up. We've had pretty remarkable success over the years in reducing central line bloodstream infections (CLABSI), central line infections, and Methicillin-resistant Staphylococcus aureus (MRSA) infections, for example. We've rolled out coordinated treatment programs that have helped prevent readmissions in these categories as well.
There are a lot of chronic care areas likely influencing ratings. For example, chronic obstructive pulmonary disease (COPD) has been a big one Medicaid has been focusing on. Hospitals with lowered star ratings may have had their services compromised to some extent due to struggles with maintaining appropriate levels of staffing or other factors that can lead to patients becoming much sicker, such as COVID-19 or not having had good routine chronic care management throughout the COVID-19 years.
Q: What are some steps these hospitals should take if they hope to improve their star ratings or at least not decline further?
GD: Most hospitals are already doing a good job of collecting data and performing their own internal quality improvement. That workaround looking at how they are performing concerning the reported measures, looking closely at their own data, and then developing internal quality control or quality improvement programs should continue.
Getting into more specifics, regarding readmissions, one of the big factors we often talk about at Cureatr is how medication-related complications, such as the wrong medication or wrong dose, can contribute to a person being readmitted within 30 days of a hospital discharge. Achieving improvements in these areas requires improvements in transitions of care and care coordination between hospital discharge and primary care. Effective follow-up requires a fair amount of rigor and coordination to make sure discharge summaries and discharge information are being transferred properly and any home services needed are being provided.
Working better with primary care practitioners and strengthening care coordination among the subspecialties, including medications, are key target areas health systems can work to improve year over year. This starts with data and a hospital being able to look and see its readmission rate for chronic conditions like COPD, heart failure, end-stage renal disease, and sepsis. Hospitals should look at these areas at a granular level and from the standpoint of the types of diagnoses and the types of management issues that frequently lead to readmissions, such as those associated with medications.
We believe medication management plays a substantial role in reducing readmission rates and therefore can have a substantial impact on improvements in star ratings. We have worked with a hospital system that went from 4 stars to 5 this past year. One of the major contributing factors was a care coordination program that reduced readmissions with the help of improved medication management.
Q: How can collaborating with an organization such as Cureatr and leveraging its Cureatr Clinic help hospitals maintain or raise their ratings?
GD: Referring back to the hospital partner I just noted, I think one of our biggest contributions concerns reducing the 30-day readmission rate. There's a growing appreciation for and focus on medication discharge plans that include a review of the medications following a discharge. This review by clinical pharmacists or other healthcare providers can help make sure patients have the medications at home they were discharged on, are not encountering any side effects or confusion concerning dosing, and are not on two different drugs doing the same thing. With a service like the one provided through Cureatr Clinic, those matters are sorted out and a medication action plan can be developed and shared with a provider to help with clinical decisions about those medications. That's one factor.
A second factor is patients are often still in a "recovery mode" when they're headed home from the hospital. In this state of mind, it's often difficult for patients to comprehend everything going on, especially when one is eager to get back to their place of comfort. Caregivers may not always be at the patient's side when medication discussions are happening in the hospital. Follow-up within the discharge period often helps patients recognize the importance of their medications and better stick to their regimen, more effectively identifying when they are confused about their regimen, following up with their provider appointments, and having the information necessary to recognize symptoms that indicate medications may need adjustment.
Medication reconciliation post-discharge (MRP) has been a longstanding tool and component of the discharge process within hospitals, but a proper MRP process requires many steps. Even in this age of digital health, it's complicated and difficult to get the right information to the right caregivers and have the patient understand this information. Cureatr can provide that conduit of reassurance to patients and caregivers about what medications are being used for and give comfort to them in knowing a highly skilled clinical pharmacist professional has reviewed the hospital information and all the medications they've been and will be on.
Our clinical pharmacists also have the capability to connect patients and caregivers with primary care providers to help with any adjustments or complications that can come up, which is especially important for those patients on many different medications for different conditions. Patients with multiple chronic conditions usually have multiple medications specific to each disorder. Those medications can often work against each other. In some cases, they can work well together but require some dose-related fine-tuning and adjustments. Patients can benefit here from the help provided by a Cureatr Clinic clinical pharmacist, often working with the primary caregiver.
CMS's incentive programs provide many different angles Cureatr can help hospitals focus on. Atul Gawande has often spoken about quality improvement as a way of identifying priorities and measures to improve. It's often very challenging to make headway on problems that face hospitals if they lack good data and don't have the capability or bandwidth to necessarily take on those problems. Another way Cureatr Clinic can potentially come into play is to take the uncertainty out of the discharge process. A patient returning home can have a pre-scheduled phone call appointment with a clinical pharmacist from Cureatr Clinic. If there are any issues that require addressing or the patient lacks their necessary medications at the time of this consultation, Cureatr helps patients acquire those medications and gets them better reconnected with their primary care doctors.
At Cureatr, we pay close attention to star ratings and their associated measures because the priorities for CMS change regularly. There are one or more new areas of focus almost every year. Some measures get essentially put on the shelf after significant improvements have been made by most hospitals, and then CMS's priorities change. Hospitals spend a lot of time internally trying to work on these issues, specifically those where they're struggling. Sometimes to unforeseen circumstances, star rating scores are not what a hospital wants them to be. While that's disappointing, it opens the door for a hospital to consider other ways in which to achieve their improvement goals that will hopefully contribute to a star rating improvement.
For hospital systems that saw a decline in their star ratings this year, and especially those that have gone from very high ratings to the middle of the pack, medication management and readmissions are likely to be big pieces of that story and areas needing greater attention going forward.