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Glens Falls Hospital is being docked about $500,000 in Medicare reimbursements because of a complex rating system that compares it to its own previous performance as well as the results at other hospitals.

But almost every other hospital in the region is also being docked after the calculation of its total performance score. The only local hospital that has increased its reimbursement rate by doing well on its performance rating is Saratoga Hospital, and it is getting only 0.4 percent more.

Maximizing Medicare reimbursement is a top goal at Glens Falls Hospital, because of its high Medicare population. Hospital CEO Dianne Shugrue said on Feb. 28 that financial problems were so dire, “we may not be here” if finances, especially Medicare reimbursements, did not improve.

But last month, after the public learned the hospital had lost $38 million in one year because of problems with a billing system, the CEO backed off on her statements of financial concern and said the hospital is doing fine.

She has continued to press for higher Medicare reimbursements. Currently, one way to get more is to be among the top performing hospitals in the country according to the federal government’s rating system, called total performance score.

On the most recent rating, Glens Falls and Albany Medical Center Hospital both got a total performance score of 30, the lowest in the region, while Saratoga Hospital got the highest, a 53. The highest rating in the state was a 65, at the Canton-Potsdam Hospital. Only 50 hospitals in the entire country scored higher than Canton-Potsdam, and only one scored in the 90s.

The low TPS score costs Glens Falls Hospital about half a percent off its Medicare reimbursement rate, which would be $488,000 based on 2017 figures, which are the most recent available. It received $68.6 million from Medicare in 2017, but reported a $29 million shortfall in actual costs versus reimbursement.

The rating system grades hospitals on a curve, so it is not possible for every hospital to get the top score. Those that do best get more money from Medicare; those that do worst lose money. To pay for it, Medicare started by reducing its reimbursement rate by 2 percent for all hospitals. It uses that pool of money to give out bonuses to reward performance.

Judged for money

Hospitals are judged on four categories. The first is clinical care, for which the federal government looks at whether patients hospitalized with heart failure, acute myocardial infarction or pneumonia died within 30 days. The rating also considers whether patients suffered complications from knee and hip replacements. Saratoga scored a 45 out of 100 for that category, while Glens Falls scored a 50. The highest score in the area was at Nathan Littauer Hospital in Gloversville, which had an 80.

The second category uses the standardized national patient survey. It asks about the facility’s cleanliness and noise, whether doctors and nurses explained things clearly, how responsive staff was to the patient’s needs, whether they were given discharge information and whether they understood it. Saratoga scored a 44, while Glens Falls got a 29. The highest score in the region was a 55, at Southwestern Vermont Medical Center in Bennington.

The third category focuses on infections. Saratoga scored a 55, while Glens Falls got a 43. Southwestern was again the highest with an 80.

The final category judges how well the hospital created efficiencies and other ways to reduce cost. Saratoga got a 70, which was the highest in the region, while Glens Falls got a zero. No other hospital in the area got a zero.

Formulating improvement

The system was designed by the Centers for Medicare and Medicaid Services to encourage hospitals to improve, said Loretta Willis of the Healthcare Association of New York State.

“It compares hospitals against themselves and then against the nation,” she said.

The system isn’t really intended for consumers to use to make decisions about which hospital to use, Willis said.

By the time CMS comes out with its ratings, the data is about two years old.

“That hospital can be doing a whole lot different work today,” she said.

So she recommended that consumers track their local hospitals, looking for trends over the course of years.

For hospitals, she thinks the ratings encourage improvement.

“Hospitals are certainly paying attention,” she said.

But she thinks the system needs to be tweaked to be effective.

Currently, the comparisons are not risk-adjusted. That means that if a hospital generally takes in sicker patients, it doesn’t have its results adjusted to take into account a higher mortality rate. Albany Medical Center Hospital regularly scores poorly on the ratings, because the sickest patients in the region are brought there from every other hospital.

“It just gets confusing for people,” said Albany Medical Center spokesman Jeffrey Gordon. “They may say, ‘Oh, Albany Med is not that good.’ But other hospitals may not be equipped to treat that patient. We have the specialists and sub-specialists, so we’re going to have the sickest of the sick.”

Healthcare Association of New York State and other agencies are working with CMS to develop a risk adjustment formula.

“But we are in the infant stages,” she said.

Overall, she thinks the rating tool could lead to better health care spending.

“I think the concept is very good, in paying for value,” she said. “Where I think it falls shorts, where hospitals get frustrated, is when it’s not truly reflective of the real good work hospitals do and consumers care about.”

For example, she’s concerned that the rating tool includes the 30-day mortality rate for patients hospitalized with heart failure.

“They will eventually likely die from that disease,” Willis said. “If they choose not to take advantage of hospice at the end of their life, they are likely to go to the hospital when they have difficulty breathing, and die.”

Hospice deaths are not counted in the mortality rate. But some patients, particularly younger people, want to try every possible medical treatment rather than accepting hospice care at the end.

“It frustrates providers because (the rating) doesn’t take into consideration all these difficult decisions,” she said. “You have people who are hanging on, and it’s their choice.”

Saratoga Hospital has a mortality review committee that looks into every death at the hospital. If there are any concerns, it’s discussed by a larger group to determine if anything could be changed to provide better care in the future.

“We treat every unexpected death as a red flag,” said Chief Medical and Physician Integration Officer Richard Falivena.

At Glens Falls Hospital, officials last year began improving access to hospice, which would improve their clinical care score. More importantly, it would give patients access to better palliative care.

Infections count

While it may be hard to judge hospitals on complex clinical care decisions, Willis of the Healthcare Association of New York State is happier with the performance ratings on infections. That’s a “perfect” measurement for consumers to use in deciding on a hospital, she said.

Glens Falls scored at a 43 for that factor, while Saratoga got a 55.

At Glens Falls, new practices to reduce infections include bathing before surgery to reduce bacteria, and a new two-step testing method that will help identify active colonies of clostridioides difficile, a potentially fatal infection, said Vice President for Planning Tracy Mills.

Saratoga Hospital has a committee that reviews every hospital-acquired infection. The committee meets once a month, and has recently partnered with the Centers for Disease Control to study catheter-related infections. They are studying who gets infected, how long they had a catheter, hospital efforts to remove catheters and other data, in an effort to reduce those infections.

“The goal is zero,” said Dr. J. Robert Hayes, Jr., medical director of hospital medicine and co-chair of the Saratoga Hospital Quality Council. “Patients are complex and often immune-compromised, but still the goal is zero.”

One of their efforts is to educate families about the increasing danger from infections as the catheter stays in. Families can then help encourage the patient to start walking to the bathroom.

Before joint replacement surgery, if it’s not an emergency, Saratoga Hospital requires all patients to take a class on how to avoid infections and blood clots, among other topics. To ensure that most patients are able to go home rather than to an inpatient rehab facility, they help the patient make a plan, which could include finding someone to stay with them for a few weeks.

“We think people rehab better at home,” Falivena said, noting that patients often go to a rehab facility with their catheter still in place and walk less than they would at home.

That effort helped earn them the highest rating in the area for cost control, because going home is much cheaper than going to rehab. Hospitals are judged on Medicare spending for the three days prior to the patient going into the hospital and the 30 days after discharge.

Cost score

Both Saratoga Hospital and Ellis Hospital scored a 70 out of 100 on “efficiencies and cost reduction,” one of the four factors that make up the total performance score.

Glens Falls fell just short of getting any points in that category. Mills noted that much of the rating involves costs before and after the hospital stay, not just the hospital’s costs.

“In this case, we did not receive points because we are on par with the rest of the nation, and maintained a consistent score” in comparison to the hospital’s previous costs, Mills said. “This is what makes these measures challenging to use for comparison or ranking.”

One rating item that is within the hospital’s control is its results on patient surveys, and on that, the hospital is seeing improvement since 2017, Mills said. That data will be reflected on the next total performance score; for now the hospital received a 29 out of 100.

“We take our patient experience scores very seriously and are always working to improve them,” Mills said.

Every comment on the surveys, as well as the scores, are shared monthly and used to make improvements, she said.

“We also continue to work with many of our departments and units on specific ways to improve scores in areas that are most important to patients,” Mills said.

Total Performance Scores

Each factor is scored out of 100 possible points, then weighted for the total. For example, 25 points would have a weighted score of 12.5.

The following hospitals scores are included below: Albany Medical Center, Albany; Champlain Valley Physicians Hospital, Plattsburgh; Ellis Hospital, Schenectady; Glens Falls Hospital, Glens Falls; Saratoga Hospital, Saratoga Springs; St. Mary's Hospital, Amsterdam; St. Peter's Hospital, Troy; Nathan Littauer Hospital, Gloversville; Central Vermont Medical Center, Berlin, Vermont and Southwestern Vermont Hospital, Bennington, Vermont. 

Source: Centers for Medicare and Medicaid Services

Factor Albany Med CVPH Ellis Glens Falls Saratoga St. Mary's St. Peter's Nathan Littauer Central Vermont SW Vermont
Clinical care 57.5 57.5 52.5 50 45 72.5 70 80 45 42.5
Patient satisfaction 14 23 18 29 44 23 27 22 29 55
Infections 30 40 26.6 43.3 55 40 51.6 60 0 80
Cost control 30 20 70 0 70 10 50 30 50 20
Total score 30.3 35.1 41.7 30.5 53.5 36.3 49.6 48 31 49.3

Total Performance Scores

Each factor is scored out of 100 possible points, then weighted for the total. For example, 25 points would have a weighted score of 12.5.

The following hospitals scores are included below: Albany Medical Center, Albany; Champlain Valley Physicians Hospital, Plattsburgh; Ellis Hospital, Schenectady; Glens Falls Hospital, Glens Falls; Saratoga Hospital, Saratoga Springs; St. Mary’s Hospital, Amsterdam; St. Peter’s Hospital, Troy; Nathan Littauer Hospital, Gloversville; Central Vermont Medical Center, Berlin, Vermont and Southwestern Vermont Hospital, Bennington, Vermont.

Source: Centers for Medicare and Medicaid Services

Factor Albany Med CVPH Ellis Glens Falls Saratoga St. Mary’s St. Peter’s Nathan Littauer Central Vermont SW Vermont

Clinical care 57.5 57.5 52.5 50 45 72.5 70 80 45 42.5

Patient satisfaction 14 23 18 29 44 23 27 22 29 55

Infections 30 40 26.6 43.3 55 40 51.6 60 0 80

Cost control 30 20 70 0 70 10 50 30 50 20

Total score 30.3 35.1 41.7 30.5 53.5 36.3 49.6 48 31 49.3

compiled by Kathleen Moore

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You can reach Kathleen Moore at 742-3247 or kmoore@poststar.com. Follow her on Twitter @ByKathleenMoore or at her blog on www.poststar.com.

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reporter - Health care, Moreau, Queensbury, South Glens Falls

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