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In addition to the vexing problem of quality measures that unfairly downgrade a hospital’s quality and safety scores, common quality measures also can boost a hospital’s scores higher than they deserve, says David Friend, MD, MBA, chief transformation officer and managing director of the Center for Healthcare Excellence & Innovation with BDO USA, a consulting company based in Chicago. That can be the result of simple error or intentional efforts to beat the system, he says.
Any data that are self-reported and used to assess the organization’s reports should be looked at with skepticism, he says. Some of the reporting tools are complex, so it is inevitable that errors can slip into the data by mistake, he says. Some incorrect data, however, are provided deliberately.
“There is a greater level of fraud in reporting this data than anyone wants to acknowledge,” Friend says. “In healthcare, a lot of quality metrics are self-reported on some level, and those measures are less reliable than objective measures. It may be unintentional or intentional, but sometimes the numbers don’t you tell you the way it really is. That is why we have accountants who do audits and why we have the Internal Revenue Service to check your numbers instead of just taking your word that they’re accurate.”
With increasing pressure to score well and not lose reimbursement, some hospitals may intentionally game the system, says Peter Bonis, MD, chief medical officer of clinical effectiveness with the Boston office of Wolters Kluwer Health, which provides data, software, and consulting for healthcare organizations. He gives the example of a quality measure that says patients should have a blood pressure of less than 140/80. A hospital could engineer a process for patients who have a slightly higher blood pressure, using medications to lower the blood pressure below the threshold even though the medication might not be truly necessary, he says.
“When everything rides on that one number, there can be a great deal of pressure to apply a quick fix and save your reimbursement rather than pursuing the usual course of changing the patient’s diet and exercise,” Bonis says. “When you have measures, people will manage to those measures. People get good at it and when you implement a new measure you see a flattening of that data. It doesn’t mean you’ve really improved anything; it just means people have focused on that and managed to those measures.”
Hospital leaders are justified in their concerns that scoring systems such as the CMS Star Ratings produce an unfair comparison, Friend says. In addition to the accuracy of the raw data, the ratings may not provide the comparison that consumers assume, he says. Consumers typically do not consider factors such as whether a hospital or physician cares for much sicker patients than another provider, for instance, and be misled by a discrepancy in their death rates.
“Data without context is meaningless,” Friend says.
Hospitals can’t opt out of these scoring systems for compliance reasons and because the country is pushing for more transparency in healthcare, Friend notes. Consumers increasingly are demanding the ability to compare and shop around for healthcare in the same way they do with other services and products, he says.
What hospitals are going to have to do is provide that all-important context. They will have to be actively working to tell their story, particularly when they think the data doesn’t necessarily reflect the whole picture,” Friend says. “They have to embrace it. If they try to fight it, they’re not going to be very happy and they’re not going to win that battle.”
Editor Greg Freeman, Managing Editor Jill Drachenberg, Associate Managing Editor Dana Spector, and Nurse Planner Fameka Barron Leonard report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Patrice Spath discloses she is author of by Health Administrative Press, and a stockholder of both General Electric and Johnson & Johnson.