As Jefferson Parish moves to lease its public hospitals to a private operator, two key questions have been how much money will the public make on the deal and how much control will it be allowed to keep. Both can be answered in relatively objective terms: by dollars and by the number of seats Jefferson retains on the hospital...
As Jefferson Parish moves to lease its public hospitals to a private operator, two key questions have been how much money will the public make on the deal and how much control will it be allowed to keep. Both can be answered in relatively objective terms: by dollars and by the number of seats Jefferson retains on the hospital governing boards.
A third important issue, but much more subjective, is quality of care. What level of care might a patient expect to receive at a hospital run by any of the three companies competing for the lease: the HCA conglomerate, Louisiana Children's Medical Center or Ochsner Health System?
The answer is more a matter of perspective and opinion. "There are factors we don't even know how to measure yet," says Nancy Foster, vice president for quality and safety policy at the American Hospital Association. "We are not yet able to answer some of the most critical questions about these hospitals, or about all hospitals."
To evaluate the best hospital for a patient depends on a myriad of factors, starting with one's own health history and personal priorities. Medicare can help make the decision, for it tracks data ranging from the quietness of a hospital room to the likelihood of a heart attack victim dying at a given Medicare-certified hospital.
But even Medicare's apple-to-apples data doesn't answer all the questions. Indeed, the search for the best universal metric of a hospital's ability to serve its patients is at the forefront of study in the health-care industry, which seeks to track the quality of a hospital's performance in part so that insurers push hospitals to maximize care for cost.
When Jefferson Parish's consultant set out to find a company to lease East Jefferson General Hospital and West Jefferson Medical Center, it didn't ask for the same set of statistics from the competitors. Instead, it asked operators what quality of care they could provide. Thus each applicant could choose what information it chose to share.
Ochsner, which owns or manages nine hospitals, all of which are teaching hospitals that treat high-risk patients, has touted its risk-adjusted mortality index. It uses private data from the Louisiana Hospital Association to show that its hospitals are more likely to save a patient's life than Children's-operated Touro Infirmary and an average of the two HCA-operated Tulane hospitals. But Ochsner's public presentation does not include the other local HCA hospital, Lakeview Regional Medical Center near Covington.
HCA has touted its "grand composite score," which uses public data from Medicare and Medicaid patients. It shows show that for established everyday medical procedures, HCA is most reliable.
Children's has stood apart. While it has run Touro Infirmay since 2009, it has a much longer history running Children's Hospital, known for pediatric care that is tracked by different metrics - but not by Medicare and Medicaid.
That makes an objective comparison all the more difficult. East Jefferson Chairman Newell Normand, who also is Jefferson's sheriff, said Monday that quality of care is a small factor in his decision-making, not because it's unimportant but because he sees the quality from the three competitors as similar.
"When we look at the quality scores, we see that the HCA's national scores as well as local scores are as good and in many cases better than our two respective hospitals and better than our suitors," said Normand, whose board backs HCA.
Ochsner executives wonder how Normand arrived at that idea. They said that at no time during the competitive process were they asked to provide specific ratings of quality of care, and that in the past six months they have been asked for additional data only on financials, rather than care statistics.
"How can they make a decision ... when they don't understand the quality information?" Ochsner President Warner Thomas asked.
Public data
To evaluate the quality of care a patient receives for a service, and to make a payment based on that quality, Medicare and Medicaid look at certain measurable factors in hospitals. They cull data from enrollment and claims, the U.S. Centers for Disease Control and Prevention and hospital certification agencies and make the data public. But because this data tracks only those customers paying with Medicare and Medicaid at Medicare-certified hospitals, it reflects a subset of the population and does not, for example, recognize patients paying with private insurance.
The Medicare-certified Ochsner hospitals that are tracked include Ochsner's main campus in Old Jefferson, Ochsner-Kenner, Ochsner Baptist in New Orleans and Ochsner hospitals in Slidell, Baton Rouge and Raceland. For this review of the public data, NOLA.com | The Times-Picayune looked at Ochsner's main campus, Ochsner-Kenner and Ochsner Baptist.
HCA, headquartered in Nashville, Tenn., runs 162 hospitals, including two local Medicare-certified hospitals: Tulane Medical Center in New Orleans and Lakeview Regional in Covington. HCA-operated Tulane-Lakeside in Metairie is a short-term acute care center, so its Medicare data is included under umbrella reports from Tulane Medical Center.
Children's data from its pediatric hospital is not tracked by Medicare and Medicaid. But its data from Touro is included.
For Medicare, an important factor in tracking payments is complications that a patient contracts during a hospital visit, said Thomas Valuck, senior vice president at the National Quality Foundation. That's because these complications are considered to be caused by the hospital environment.
In publicly available data, for most categories of complications from July 1, 2009, to June 30, 2011, all three companies had rates that were similar enough to the national average as to not be significant. However, HCA's Tulane Medical Center scored worse than the national rate in two categories: "serious complications" and "deaths among patients with serious treatable complications after surgery."
Another factor in evaluating care is the efficiency of a hospital's administration, Valuck said. A common measure is how quickly an emergency patient is seen, diagnosed and admitted as an inpatient. An inefficient administration might affect a patient's health, increasing risk and discomfort.
In this respect, Children's Touro and the local Ochsner hospitals fare poorly. Their emergency room patients wait longer than the state and national average to see a health-care professional. HCA's local hospitals beat both the state and national average.
Among the most significant of public statistics is a hospital's rate of adjusted mortality, which evaluates how likely a patient is to die at a hospital when adjusted for conditions such as a patient's age, medical history and disease. Public data tracks mortality rates for three specific diseases: heart disease, heart failure and pneumonia.
For all three Jefferson hospitals lease competitors, and for East Jefferson General and West Jefferson Medical Center, mortality rates equal the national rate in all cases but one. The exception: At Children's Touro, a patient suffering from heart failure was more likely to survive than was reflected by the national average mortality rate of 11.7 percent
Private data
In addition to publicly reported data, private listings and health-care information storehouses cull, repackage and research further to rate the quality of hospital care. They tout their reports as clearer and more accurate measures of a hospital's performance.
But private listings of hospitals rank the three Jefferson competitors differently, even on similar categories.
Consumer Reports generates a "safety score," based on some of the same public information available through Medicare and Medicaid databases: rate of infection, readmission, appropriate use of chest and abdominal scanning, avoidance of serious complications and how doctors and nurses communicate about medicine.
Its rating gave Children's Touro the highest safety score of the three competitors, 46 out of a possible 100. The Medicare-certified local Ochsner hospitals averaged 43.6, the two Medicare-certified HCA hospitals 33.5.
Ochsner looks better at Healthgrades.com, which evaluates hospitals on a five-star system that considers patients who experienced complications or died as a result of certain treatments. It uses privately collected data of Medicare-certified and non-Medicare-certified hospitals to give five-star awards to those that saw better-than-expected mortality rates per procedure.
At healthgrades.com, Touro was rated as better-than-average in six categories, HCA's local hospitals in five. Four local Ochsner hospitals averaged 17 each.
Ochsner also has prided itself on its better-than-average mortality ratings. In a presentation to the Jefferson Parish Council, it shared a slide that showed its overall rate-of-mortality index at its eight Louisiana hospitals, as well as a local average of its Baptist, West Bank and Kenner campuses, to be lower than the national average, and significantly lower than Children's Touro and HCA's Tulane.
To Ochsner, these ratings are the most important piece of the patient care picture.
"The first thing we begin to look at is mortality: How do people do?" Ochsner's Thomas said. "If you went into the hospital for a procedure, did you die? Or did you come out the way you were supposed to -- better."
The Children's Hospital of New Orleans prefers to trumpet its own patient satisfaction data, primarily provided out by adult caregivers, spokesman Brian Landry said. The hospital is proud of its 4.88 out of 5 patient satisfaction rate, which shows that 97.6 percent of parents thought their children received excellent care. "The pediatric population is different than the adult population," Landry said. "It's a little more difficult to come up with the correct questions to ask... We want to know and make sure that our patients are satisfied with the services we provide and show areas we may need to improve."
Children's Touro also is difficult to compare to HCA and Ochsner, as it is a smaller community hospital that refers out patients who need hyper-specialized care, said Christine Albert, associate vice president of marketing. "When you compare us to a teaching facility, like at Tulane or Ochsner, we don't have hyper-specialized programs like organ transplant," Albert said. "Touro is a high-quality, community-based hospital."
Albert stresses Touro's friendly, warm reputation and its place in a report showcasing best practices in the country from the Hospital Engagement Network, a group of hospitals that share information to improve performance. "Like everyone, we really focus on the data," Albert said. "But we qualitatively hear from our patients that they like the experience, the friendly, warm and welcoming environment. That's something we hear a lot."
Regardless, some health-care analysts are skeptical of how full a picture Ochsner's measure, the mortality index, can paint when taken on its own. Foster, of the American Hospitals Association, said many of the sickest patients are referred to the best hospitals. The result, she said, is that some of the most respected hospitals have the highest mortality rates.
"Mortality rates might say something about the quality of care hospitals provide, but more likely it says something about the sickness of the patients being sent to those hospitals," Foster said. "You can design a measure to try to take that sickness out of the equation, but it's not enough."
The methodology used to adjust these mortality rates is developed and owned by the privately-held Truven Health Analytics. An HCA spokesperson, Kristian Sonnier, noted that while HCA does not have as successful risk-adjusted mortality rates as Ochsner, it is still highly rated by Truven Health Analytics, which incorporates its risk-adjusted mortality index rates with other private data to come to a list of 100 Top Hospitals. As a result, 10 HCA hospitals in the United States made the list, Sonnier said. Ochsner Health System on a whole was listed in Truven's list of best "Medium Health Systems." Children's Touro was not listed.
Darryl Nelson, HCA's chief medical officer, said his company prefers to track day-to-day expectations of hospital care, called "core measures." These are the measures tracked by Medicare and Medicaid.
"We have stuck by the gold standard," Nelson said. "Which is that grand composite score, driven off of core measures, defined a decade or longer ago by the Center for Medicare and Medicaid, by the government. They are expectations of care that should be delivered not just on occasion, but to every patient every time."
For a web presentation, HCA tabulated a "grand composite score" of those core measures, ranking an average of its top 10 U.S. hospitals significantly above the performance of Children's Touro and Ochsner's eight-hospital system.
Ochsner's medical director for quality, Sandra Kemmerly, downplays the significance of this data, saying the "grand composite score" was a measurement that HCA had developed on its own, not a nationally accepted standard. Thomas, the Ochsner CEO, said tracking core measures does not significantly differentiate care among the competitors, as every hospital scores highly enough that the gaps between them are not significant.
HCA's slide shows that Ochsner and Children's-run Touro scored higher than 94 percent on core measures. It shows the average data from HCA's two Tulane hospitals -- the Medical Center in New Orleans and Lakeside in Metairie -- at 98.48 percent, its Lakeview hospital at 99.03 percent.
Ochsner prefers to note that among the three competitors, it runs the only hospitals ranked anywhere on U.S. News and World Report's list of best hospitals, and that they are rated so in eight types of care. That is in part because Ochsner runs specialized medical programs in its hospitals, and U.S. News and World Report does not track typical community hospitals but instead seeks out hospitals that show high performance on the most medical procedures.
Valuck said comparing a high-performing teaching hospital such as Ochsner to a community hospital, such as Touro, might not be fair. "That may make it look like comparing apples and oranges," he said.
"We use the U.S. News and World Report not just because we look good in it. It's the gold standard, " said Ochsner's Thomas. "The reason HCA doesn't want to use it is because they're not listed in it. They're the largest hospital company in the country, and they're not listed in it."
A sheet that Ochsner distributed to Jefferson hospital officials compared Ochsner's eight Louisiana hospitals' ranking in U.S. News only to HCA's Tulane Medical Center, rather than other HCA-run hospitals.
"We have hospitals in certain markets that have areas of expertise and have been identified through U.S. News," said HCA's Nelson. "But even in those markets, our prioritization is around patient experience and core measures."
How patients choose
To choose a hospital, however, the average patient does not consider any of these rating systems, said Foster of the American Hospital Association and David Hefner, vice president of Regents Medical Center in Augusta, Ga., and a former senior adviser at the Association of American Medical Colleges.
In an emergency, the nearest hospital is the best. And outside of an emergency, most people choose hospitals that their insurance programs will cover. Beyond that, patients choose hospitals recommended by those they trust -- doctors, neighbors, friends and family -- Foster and Hefner said.
"If you had to go to the hospital tomorrow, you would talk to friends and family, and people like me," Hefner said. "What do your friends and family tell you, reputation-wise?"
A survey conducted by Medicare and Medicaid, with the Agency for Healthcare Research and Quality, is designed to determine whether a patient would recommend a hospital experience. The survey, called the Hospital Consumer Assessment of Healthcare Providers and Systems, asks a random group of patients questions ranging from how quiet their hospital room was to whether their nurse explained a procedure clearly.
"The HCAHPS survey was designed to be as if you were leaning across your backyard and talking to 5,000 friends who all had experience at hospital A and 5,000 who had experience at hospital B," said Foster. "You really get a sense of what would your experience be like."
On HCAHPS data from Oct. 1, 2011, through Sept. 30, West Jefferson Medical Center and East Jefferson General were more likely than a selection of hospitals run by their three suitors to be recommended by patients: 75 percent of patients at each public hospital said they would recommend it.
For Children's Touro, it was 72 percent. For local HCA hospitals, it was 70 percent. For three local Ochsner hospitals, it was 69 percent.
HCA's Nelson said the company's hospitals do not prioritize HCAHPS, because they place a higher value on saving a patient's life. "Say you got somebody in with a heart attack," Nelson said. "You may not deliver all of the ideal patient experience because you're time-limited."
Valuck, of the National Quality Foundation, said hospitals, of course, should prioritize life-saving over patient experience. But comfort and good relationships with doctors and nurses is shown to help patients recover, he said.
Foster said that whatever method a hospital chooses to track its quality, it should show improvement. These tests of quality are in place, after all, to motivate hospitals to provide excellent care.
"I want it so everyone can choose the hospital they go to based on the quality of the food," said Foster. "Because they know everything else is very high quality."
Evaluating Patient Experience |
|||||
| East Jefferson | West Jefferson | Ochsner average* | HCA average** | Touro*** | |
| Patients who reported that they "Always" received help as soon as they wanted. | 57% | 68% | 59% | 61% | 55% |
| Patients who reported that their pain was "Always" well controlled. | 73% | 72% | 66% | 70% | 71% |
| Patients who reported that staff "Always" explained about medicines before giving it to them. | 65% | 63% | 59% | 62% | 61% |
| Patients at each hospital who reported that YES, they were given information about what to do during their recovery at home. | 84% | 85% | 82% | 87% | 85% |
| Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest). | 67% | 75% | 67% | 68% | 69% |
| Patients who reported YES, they would definitely recommend the hospital. | 75% | 75% | 69% | 70% | 72% |
* Ochsner main campus, Ochsner-Kenner and Ochsner Baptist |
|||||
. . . . . . .
- See background on Jefferson's hospitals and the three competing operators
- Public reports on the quality of care at a given hospital are available on the HospitalCompare webpage of the Centers for Medicare and Medicaid.
- Some helpful public ratings of hospitals are available for public view at U.S. News & World Report's list of Best Hospitals, at Healthgrades.com, at Leapfrog.com and Truven Analytics' 100 Top Hospitals. Readers may subscribe to Consumer Reports to access its reports.