Federal ratings for Valley hospitals range from one star to five

Aug. 06--The federal government has released new hospital quality ratings, and the news is good and bad in the central San Joaquin Valley.

The region has a top-rated hospital -- and one of the lowest-scoring.

Fresno Surgical Hospital earned a five-star score from the Centers for Medicare & Medicaid Services, which rated more than 3,500 hospitals nationwide on a one-to-five-star system, with five stars being the highest rating.

The doctor-owned hospital was one of nine in the state to receive the top five-star rating, according to an analysis by Kaiser Health News. Nationwide, 102 hospitals got five stars in the ratings released in late July.

Of the lowest-scoring hospitals, Tulare Regional Medical Center was one of 11 in California to get a one-star rating. Nationwide, 129 hospitals were given the one-star rating.

No hospital in the Valley earned four stars. Nationwide, the most common rating was three stars. In Fresno, Kaiser Permanente-Fresno and Fresno Heart & Surgical Hospital each earned three stars. Kaweah Delta Medical Center in Visalia also received three stars.

The Centers for Medicare & Medicaid Services has tracked hospital quality measures, such as readmission and infection rates, for years. Medicare has penalized hospitals for too many readmissions and high infection rates. But the latest star scorecard uses 64 measures to calculate quality in several categories -- readmission, deaths, patient experience, timeliness of care, complications, use of medical imaging and payment/value of care -- to give an overall quality rating.

What do hospitals say about the ratings?

The star rating system has come under fire from hospital executives nationwide. They have criticized it for penalizing safety-net hospitals that serve the poor by ignoring socioeconomic factors, such as patient income. But the federal agency has stood behind its scorecard, saying the measures do provide an easy means for consumers to gauge hospital quality.

On Thursday, officials at Tulare Regional Medical Center released an email statement saying that they "agree with the American Hospital Association's assertion that the one-star rating system is inconsistent and too confusing for patients trying to determine the overall value of a score."

The system also doesn't accurately reflect the challenges faced by rural safety-net hospitals, such as Tulare Regional, they said. And the officials cited the age of the 112-bed hospital as a factor affecting its quality rating.

Tulare Regional has a new hospital under construction, but the half-completed project all but stopped three years ago when the health care district ran out of construction money. To finish the project, voters in the health district are being asked to approve a proposed $55 million bond, which requires two-thirds vote to pass. Ballots in the mail-only election will be counted Aug. 30.

Community Regional Medical Center, the region's largest safety-net hospital, received two stars from the federal government. The measurements used by the government to measure quality can be difficult to meet for hospitals with high-risk populations, said Dr. Thomas Utecht, chief medical officer for Community Medical Centers. The hospital system operates the downtown Fresno regional center, Fresno Heart & Surgical Hospital and Clovis Community Medical Center.

"We are a very, very busy hospital trying to care for high volumes of patients," Utecht said. "And we live in a very socioeconomically challenged environment."

Kristine Kassahn, chief executive officer at Fresno Surgical Hospital, the Valley's only five-star hospital, said the government ratings are fair. While the hospital doesn't have an emergency department or trauma unit, it does a high volume of surgeries, she said. And it has maintained high ratings for customer service and for quality of care.

"The mission of this facility has been the same since 1984 and that's customer satisfaction, whether that's the patient, the surgeon or the employee," Kassahn said. "We consider all of that the customer."

How has patient care changed?

Government ratings, liked or not, have become staples of health care.

And there are indications the scrutiny has made a difference in the patient experience.

Five years ago, the federal government began penalizing hospitals for readmitting too many patients within a month of discharge. As a result, that wheelchair ride to the curb no longer is the last contact patients have with their hospital.

It's now routine for hospital nurses to call patients at home to check on their health. Most hospitals try to contact patients within a day or two of discharge.

And that's only one of the strategies to keep patients from returning.

Teams of doctors and nurses and support staff are devoted to reducing readmissions, which is among the categories included in the government's new star ratings.

"There's a lot of discharge planning that starts from Day One when the patient is admitted here at the hospital," said Dr. Edward Hirsch, vice president-chief medical and quality officer at Kaweah Delta Health Care District in Visalia.

At Adventist Central Valley Network, which operates hospitals in Hanford, Reedley and Selma, seven task forces work to keep patients from coming back. "We have so many things going on that it reminds me of an orchestra," said Diane Hoyt, vice president of quality and patient safety.

Nationwide since penalties for returning patients went into effect, readmission rates have decreased at many hospitals. But according to an analysis by Kaiser Health News, the government will penalize more than half the nation's hospitals over the next year for more than half a billion dollars. And, according to the analysis, Medicare has penalized five of the 13 hospitals in the four-county area from Madera to Tulare every year since penalties were first assessed.

This spring, a state report found the Affordable Care Act appears to have had an initial effect on lowering readmission rates in California.

According to California's Office of Statewide Health Planning and Development, readmission rates for heart attack patients fell by nearly 12 percent from 2007 to 2013. And readmission rates for heart failure and pneumonia dropped by 6 percent and 4 percent, respectively.

The state agency concluded that the Affordable Care Act, which beginning in 2012 mandated that hospitals reduce Medicare readmissions in those three patient-care categories, appears to have cut readmission rates for not only Medicare but also non-Medicare patients.

But Valley hospital executives are disinclined to give the Affordable Care Act credit.

The Affordable Care Act, also known as Obamacare, has provided insurance to hundreds of thousands of people in the Valley, but it hasn't increased access to primary care doctors that hospital patients need to remain healthy when they go home, officials said.

Through the health-care law, California has added people not only to private insurance plans, but also to Medi-Cal, the state-federal insurance for low-income individuals and families. But many doctors in the Valley and state refuse to take Medi-Cal patients because of low reimbursement.

"Getting an appointment within a week of discharge is nearly impossible for that population," Utecht said.

Hirsch said Kaweah Delta places a priority on making outpatient appointments for patients before they are discharged, but often the only sources of care for Medi-Cal patients are federally qualified health centers and rural health clinics. "If it wasn't for those, I'm telling you we would have a readmission rate of 60 percent," he said.

What are hospitals doing?

Hospitals are opening their own specialty clinics for patients who need follow-up care after discharge. Kaweah has opened a chronic disease management center to improve access to doctors, therapists and dietitians for patients with diabetes and heart problems. Those patients see a doctor within three days, Hirsch said. "That's made a huge difference."

The Visalia hospital also has a "meds to beds" program. Before patients leave the hospital, they can get their prescriptions filled. "They walk out with a brown bag of medications," Hirsch said.

Adventist Medical Center-Hanford has a lung care center for patients who have pneumonia, asthma and other respiratory conditions. Hoyt said the center is reducing readmission rates by educating patients on disease management. One of the center's doctors estimates that 60 percent of the patients referred to the center were not properly using their medications.

And Adventist is developing a complex care clinic for chronically ill patients, Hoyt said.

"We are getting away from the word 'discharge' and are using 'transition,' " she said. "We feel they are never out of our care -- either in the inpatient setting or outpatient setting."

Saint Agnes Medical Center in northeast Fresno has one of the highest Medicare patient populations in the Valley and has found connecting patients with home health services can keep them from returning to the hospital.

Heart attack and heart failure patients also are being remotely monitored for fluctuations in blood pressure and weight that can signal a change in their health.

And sometimes the hospital helps with something as simple as a ride to the doctor's office. "It's a real need for those people in the community who don't have a support system to help them be compliant with their treatment plan," said Julie Cade, director of quality, safety, accreditation and risk management.

But despite all the efforts to reduce readmissions, hospitals continue to struggle to meet Medicare expectations.

The Centers for Medicare & Medicaid Services has added health conditions to the heart attack, heart failure and pneumonia categories that it has been tracking. Hospitals now must reduce readmissions for chronic pulmonary obstructive disease, knee and hip joint replacement and coronary artery bypass graft surgery.

Cade said the strategies remain the same: get discharged patients into primary care doctors and therapy, follow their progress by phone calls and remote monitoring, make sure they have medications and transportation to doctor appointments.

And so far, so good, she said. "Actually, readmission rates for the surgical, orthopedic patients has been good and has been better than the national readmission rate."

Barbara Anderson: 559-441-6310, @beehealthwriter

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