Rural Hospital Tracks Shift to Value in CMS Star Ratings

cms-logo-smallOnly 20% all hospitals scored a Four-Star rating from the Centers for Medicare & Medicaid Services. One rural hospital CEO talks about getting the message out to patients and their families about the high quality care delivered locally.

Susan Starling, CEO of Mercy Health's Marcum and Wallace Memorial Hospital in Irvine, KY says she's reasonably happy with the Four-Star rating her 25-bed critical access hospital received from the Centers for Medicare & Medicaid Services. That is, until she has to explain to patients why the hospital didn't merit Five Stars.

"I don't think the patients or their families understand the whole rating system," Starling says. "We may perceive Four Stars as really great because there aren't many Five Stars in the U.S., but I don't know that patients understand. They want to know why we're not Five Stars."

Although much of the rankings are based upon patients' perception of their care, Starling says "it's a complicated rating system that is not really set for patients to be able to have a good understanding of what the ratings mean."

"In our market area we do well compared to our competition, but I am not sure how you can market that," she says. "There is opportunity to do that, but I don't know what it is."

Like many hospital leaders, Starling says Marcum and Wallace scores well with the factors it can control.

"Our hospital has high scores in cleanliness. We focus on making it a good patient experience. In a rural hospital we are family and friends caring for family and friends," she says.

Bigger is Not Always Better

"It is a positive environment for our patients where they have good outcomes. They feel comfortable being here. That misnomer of 'bigger is better' is not always true. Our culture is to provide good care to our patients, which is reflected in our rating."

The demerits come, she says, when Marcum and Wallace is hit for factors over which it has little control: For example, payer-mandated discharges that are perceived as premature by patients, and post-discharge care services in a rural region with scarce resources.

"More and more we are trying to get the patients back out into the community, but in rural settings there are often limited options for after-hospital care," Starling says. "We do the best we can, but really patients sometimes aren't ready to go home, even if Medicare or their insurance carriers are demanding that they get back out into the community."

"We don't have a lot of access to home health services and those things such as Meals on Wheels and we have limited physical therapy services out into the community. Those are the challenges that we face in rural that makes it harder to get a better score on post-hospital settings."

To compensate for a lack of resources, Starling says Marcum and Wallace does "everything we can to make it a successful discharge. We work really hard on trying to make sure they have everything they need, the education, the medications, the tools. But again, if that patient goes home and they don't physically feel that they are ready, maybe they don't have the support system at home, then we don't get a good rating, even though we don't have a lot of control over that part of it."

The hospital's attempts to provide resources for a post-discharge care network are hampered by a lack of money.

"Home health pulled out of rural communities because it is not financially feasible for them to be here. Investing in those services is not a good financial move on my part," Starling says.

"The government is not looking at the needs of rural America, and the reimbursement for home health in rural, so the services are just pulling out. The durable medical equipment companies are pulling out of rural as they face these financial challenges. We are the first to get cut."

With the goal of someday achieving a Five-Star rating, Starling says Marcum and Wallace is borrowing strategies from accountable care organizations and forging ahead with new initiatives.

"We are working closely now with a care coordinator in our physician clinics and making sure she understands what is happening with the patients when they are in the hospital, so that when the patient is discharged the coordinator is aware of it," she says.

"We are looking at the patients' different needs and services that they'll need and trying to coordinate that. We just received a federal grant that is going to help us work on medication therapy for the patient and have a pharmacist in some of the clinics help these patients have a better understanding of their medications and monitor them and what the patient understands, what exactly is this medication for."

Using ACO strategies makes sense even if you're not in an ACO, Starling says, because the star ratings are part of larger movement to measure the efficacy of patient-centered and value-based care that hospitals provide.

"Now we are cost based, but that going to change for critical access hospitals," she says. "My goal as the CEO is to try to improve the health of our patients, do the things that we think can help our patients with respect to population health. I am laying the foundation to be prepared for the future, whatever the future is."

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