NPR’s “Talk of the Nation,” Featuring Don Berwick and Yours Truly

Medicare is now reporting actual risk-adjusted mortality rates for pneumonia, MI, and heart failure. The topic must be important, since “Talk of the Nation” spent 30 minutes yesterday interviewing Don Berwick and me about it… on the day of Hillary’s speech!

To listen to the show, click here. Also, here’s an article from USA Today that got the ball rolling, as well as Avery Comarow’s thoughtful blog on these new reports.

Here are a few observations about the new CMS (Centers for Medicare & Medicaid Services) initiative, some of which I made on the NPR broadcast:

  1. First, I see this as a healthy and inevitable trend. We are moving away from a singular focus on process measures – which have real advantages (no need for case-mix adjustment; they can be measured at the time of care) but are too narrow and game-able – and toward blending in reports of outcomes. There are now two kinds of outcomes on the CMS site: the mortality rate reports join patient experience surveys, which were added earlier this year.

  2. Second, the science of case-mix adjustment, while still imperfect, is finally good enough for government work (which is, after all, what this is). The brains behind the methodology come from a team led by my old UCSF colleague Harlan Krumholtz, a world-class cardiology outcomes researcher at Yale. And the science will drastically improve as we transition to computerized medical records, which will allow more of the data (both the outcome data and the case-mix adjustment variables) to be drawn from clinical notes rather than billing records.
  3. Third, I think the researchers and CMS made several good decisions about how to run and present the reports. Such as…
    • When a patient is transferred from one hospital to another (such as from a community hospital to an academic medical center like UCSF), any death is attributed to the first hospital. A decision otherwise would have created an incentive for higher-level hospitals to refuse transfers of patients who seem likely to die.

    • The reported mortality rates are 30-day rates, not in-hospital rates. This does a couple of useful things. First, it removes an incentive for gaming the discharge decision for dying patients (some patients are best allowed to die in the hospital rather than being hustled out to a hospice or home for their last few days). More importantly, a 30-day rate causes hospitals to focus on post-discharge care, stepping up our heretofore-wimpy efforts to ensure a good transition to home. (Parenthetically, there is also a lot of interest in switching to “bundled payments” for “episodes of care” rather than DRG payments for the hospitalization only… yet another strategy designed to push hospitals to improve their discharge process). All of this is part of a macro-trend to de-silo the hospitalization and catalyze a new focus on post-discharge care. This is a healthy change.
    • Finally, while reporting the raw mortality rates and their statistical precision, CMS chose to place hospitals in only three buckets: “average,” “below average,” and “above average.” This means that those who want “rankings” may be disappointed by the HospitalCompare data. For example, of 9 acute care hospitals in San Francisco, none had mortality rates for any of the three diseases that were deemed significantly different than the national average. Don called this conservative reporting strategy the product of “a little bit of
      timidity” on CMS’s part, but I was more supportive – I think it
      would be scientifically irresponsible to rank a hospital as “below
      average” when its results aren’t statistically different from the mean.
      (I’ll be less charitable if, over time, persistent outliers are not
      branded as such.)

From a user-friendliness standpoint, the site now includes an interactive map that allows you to drill in on hospitals in a city, and a pretty good compare function that allows one to contrast the performance of several hospitals at a time. We’re not quite at the Consumer Reports, “Let’s Compare the Lexus to the Infiniti,” level of sophistication and user interface, but it has gotten much more snazzy and accessible.

That said, I continue to believe that the real value of these reports comes not from consumer choice – most people are going to go to their local hospital, particularly in an emergency. Instead, the reports create tension for change inside hospitals – nobody wants to look bad, and nothing focuses a CEO’s or hospital board’s attention more than seeing publicly reported data that appears to indicate that you’re killing more people than you should. By “turning the lights on” (in Don’s words) in hospital care, the CMS mortality reports should promote more vigorous efforts to improve quality and safety.

I call that progress.   

2 Responses to “NPR’s “Talk of the Nation,” Featuring Don Berwick and Yours Truly”

  1. menoalittle August 29, 2008 at 5:18 am #

    Bob,

    Interesting stuff, though it is amazing how many patients with pneumonia who get antibiotics within 240 minutes quickly resolve their infiltrates after a dose or two of diuretics. Likewise, the creative coding of hospital profit expanders will now be programmed (new business for the consultants) to include tweaking the diagnoses and risks with reminders to the always obliging paraprofessionals to add key words to the record. Does the coding accurately reflect the disease especially in cases of ambiguity? Perhaps you will expand on the risk adjustments and CMS methodology? What is heart failure? What is pneumonia? Do the coders know? How does CMS know that a patient died 29 days after discharge?

    Best regards,

    Menoalittle

  2. chris johnson August 29, 2008 at 4:24 pm #

    I’m all for somehow working outcomes measurement into the equation of how hospitals and physicians get paid — process measures are useful, but are not good proxies for outcomes. But to me the big issue is how to handle all the chronic conditions, since managing them accounts for about 80% of healthcare expenses. It will be tricky to figure out ways to encourage and reward good practices that pay off years later, or even decades.

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