STAR-CROSSED

CENTERS FOR MEDICARE AND MEDICAID SERVICES

Ballad Health System's flagship acute care hospitals again scored poorly in the Centers for Medicare and Medicaid Services Star ratings but health system officials claim the rankings are unfair, can be confusing and potentially cause consumers to make dangerous decisions.

In the most recent ratings issued July 26, Bristol Regional Medical Center and Johnson City Medical Center — two of the system's largest, most heavily staffed, tertiary care facilities — received one star on the CMS five-star scale. Holston Valley Medical Center, Ballad's third major tertiary care facility, received two stars.

It represents the latest round of poor rankings under the Star system for this region's most important health care facilities.

By contrast, Ballad's Smyth County Hospital received five stars while Indian Path in Kingsport and Sycamore Shoals in Elizabethton each received four stars, Franklin Woods in Johnson City and Lonesome Pine Hospital in Big Stone Gap each received three stars and Johnston Memorial in Abingdon received two stars.

Nationwide, 248 hospitals both large and small received one-star ratings.

In the Internet age, people go online to check and leave ratings and reviews for practically everything — from restaurants, hotels and cruise lines to shopping preferences. Consumers often consider such ratings in making purchases and decisions.

"These are not hotels. These are really complicated organizations," said Alan Levine, president and CEO of Ballad Health System, who cautions that potentially lifesaving decisions should not be based solely on a single rating.

Ballad was established in 2018 from former rivals Mountain States Health Alliance and Wellmont Health System, in a move approved and overseen by the states of Tennessee and Virginia.

"What has changed since the merger is we have deliberately channeled our highest risk patients to JCMC, HVMC and BRMC, thus putting a disproportionate burden on those hospitals when it comes to Star ratings," Levine told the Bristol Herald Courier last week.

The complications and mortality of sicker patients are then attributed to those hospitals, which Levine calls "one of the major flaws of the rating system."

CMS Star rating system

The Centers for Medicare and Medicaid have issued hospital ratings since 2016. The agency began issuing similar star ratings for nursing homes in 2008.

"The overall star rating for hospitals summarizes quality information on important topics, like re-admissions and deaths after heart attacks or pneumonia," according to the CMS website." The overall rating, between 1 and 5 stars, summarizes a variety of measures across five areas of quality into a single star rating for each hospital. The five measure groups include mortality, safety of care, readmission, patient experience and timely and effective care.

"The overall rating shows how well each hospital performed on an identified set of quality measures compared to other hospitals in the U.S. The more stars, the better a hospital performed on the available quality measures," according to the Medicare website.

On the front of its ratings page, Medicare advises consumers on how to best utilize the information.

"Star ratings can give you information and help you compare hospitals locally and nationwide, but you should consider a variety of factors when choosing a hospital, like physician guidance about your care plan. Along with the overall rating, you should look at other aspects of hospital quality like rates of infection and complications, and patients' experience of care based on survey results."

Researching that data requires sifting through a series of packed spreadsheets, information about improvements and declines and an exhaustive series of web pages listing everything from patient survey results to complications and deaths.

Creating accountability

When it comes to evaluating health care facilities, Levine helped write the book. In 2004, as Florida's health secretary, Levine established the nation's first state reporting of hospital outcomes.

"We were the first to create hospital transparency. I created it in Florida and then brought it to Louisiana," Levine said, adding he was subsequently asked by the federal government about applying the program on a national scale.

"My advice at the time was go condition by condition, service by service and identify what characteristics hospitals do that leads to better outcomes and measure a process of care measures," he said. "They veered, at some point in 2015 or 2016, and decided they wanted to have a simple system so they created the Star ratings.

"It came out in 2016 and was widely panned. CMS went back to the drawing board and Congress acted. They asked them to delay the Star ratings but they didn't. They changed the methodology and changed it again in 2020," Levine said.

Levine argues the system — which measures only traditional Medicare patients — doesn't include socio-economic factors and health co-morbidities in its rankings.

"It would be easy to conclude I'm making excuses. I'm not. As long as the Star rating methodology is what it is now, and all these other variables are true about our region, it's not going to change dramatically. Smyth County will be five stars and Bristol and Holston Valley will be one and two stars," Levine said.

A former Medicare executive, with knowledge of the rating system, spoke with the Herald Courier on background, on the condition of anonymity, due to this person's current position.

The former official agreed with Levine's assessment "100%" that the ratings don't take into consideration social determinants, economic levels or general health of patients.

Efforts were made to improve the rating system's ability to accurately reflect hospital outcomes but the issue is "complicated," changes occur slowly and the process can become "political."

One change to the rating process, for example, could reflect poorly on some hospitals and cast others in a better light.

"Are these ratings fair? Are they accurate? Do they really represent what is going on? I think it's fair to say they don't or that there are some caveats to all of this," the former official said.

Patients from "lower socio-economic status" or who have more social determinant issues "definitely impacts their health so they're coming in as a sicker population," the former official said.

The Ballad argument

In 2021, Ballad's "big three" hospitals all saw their Star ratings improve from one star to two. In an email to his board of directors at that time, Levine declined to promote the change because of ongoing concerns with the rating system.

He said this region's challenges — including poverty, above average rates of cancer, diabetes, obesity and behavioral health — combine to skew the numbers when the sickest are combined in those three facilities.

"I have always had concerns about oversimplifying measurements of health care organizations because I've not yet seen a methodology that adequately accounts for poverty, social determinants and the variations in the populations hospitals serve," Levine wrote in the May 2021 email to the Ballad board of directors.

As an example, he compared local results to some comparably sized Nashville hospitals that received three and four-star ratings. However they serve a population that includes 50% with commercial insurance compared to the 20% of commercially insured patients in this region, Levine said.

"The Star ratings are comparing two unlike populations," Levine said. "They're comparing Sullivan County hospitals with a 25% Medicare fee-for-service population with Davidson County, which has a 50% Medicare pay-for-service population. You can't compare that. That's only one of the issues."

This region's population also varies widely in Medicare coverage. In Washington County, Tennessee, 54% of Medicare consumers are enrolled in a managed care plan, or HMO. The rate is 63% in Sullivan County but 75% in more rural, less populated Hancock County.

The Star ratings are limited only to Medicare fee-for-service populations and don't include lower acuity, healthier patients in Medicare Advantage plans.

"The population of patients in [Ballad] hospitals are sicker, higher acuity and more likely to experience infections and other issues," he said.

One case in point is diabetes. Rates are on the rise nationally with 11% of the U.S. population diagnosed with diabetes, according to the U.S. Centers for Disease Control and Prevention.

Tennessee's diabetes incidence rate ranks among the five highest states in the U.S., at 14%. All 10 Tennessee counties within Ballad's service area ranked between 11% and 18% — at or above the national median.

Diabetes in adults, especially if untreated, can create a whole range of complications including heart disease, chronic kidney disease, nerve damage, and other problems with feet, oral health, vision, hearing, and mental health, according to the CDC.

A review shows this region has higher rates of cancer, cardiovascular and diabetes-related deaths than the rest of Tennessee or the U.S.

Suicide rates are higher here than the national median, as are the levels of opioid medication prescriptions, non-fatal overdoses and babies born with neo-natal abstinence syndrome.

Other sources

Both the Tennessee and Virginia Departments of Health monitor Ballad's health care and financial performance on an ongoing basis. Neither relies on the Medicare Star ratings as a measure of quality under the Tennessee COPA or Virginia Cooperative Agreement which were used to establish the Ballad system.

"For hospital quality performance, quality monitoring measures will include CMS Hospital Compare measures. Hospital Compare measures that are identified as target quality measures and measures of payment and value of care will be excluded from quality monitoring measures, according to the Tennessee Department of Health's overall evaluation document.

"Quality monitoring measures will be evaluated for the entire patient population and will not be restricted based on the patient's payor status. Specifically, these measures will not be limited to the Medicare population," according to the TDH document.

In 2021, the American Hospital Association issued a statement saying, "CMS's failure to account for social risk factors in calculating measures like readmission biases the ratings against those hospitals caring for more vulnerable patients.

"Star rating methodology has changed frequently and significantly since its inception comparing a current rating to a previous rating could be very misleading," according to the association.

In 2019, the New England Journal of Medicine asserted that "all hospital rating systems are flawed." The publication ranked all of the hospital quality measuring services available and gave the CMS Star system a "C" grade, terming the system "mediocre." It rated U.S. News rankings highest with a grade of "B." LeapFrog received a "C-minus" and Healthgrades received a "D-plus."

That report was also critical because the CMS ratings are based solely on data from patients with traditional Medicare.

Levine said Ballad hospitals have received high marks from other rating services, including U.S. News, The Joint Commission, Blue CrossBlue Shield and Quantros. Ballad does not participate in the LeapFrog health ratings, Levine said, because the process is "extremely labor intensive" for system employees since it requires self-reporting.

The Joint Commission accredits hospitals for the Medicare program. Ballad sought and received Joint Commission special certification in specific categories for some of its hospitals, including BRMC. Additionally, Blue Cross Blue Shield identified two Ballad hospitals — Bristol Regional and Holston Valley — among just four statewide in Tennessee that it classifies as efficient.

"They can't all be wrong," Levine said. "So to simplify all of this into a star rating when all of these things are true does a huge disservice to the hospitals and to the community. Because the worst thing that can happen, if someone has chest pains but says 'Bristol has a one-star rating, I'm not going there. I'm going to Sycamore Shoals or Smyth County because they're five-star.'"

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