If It Wasn’t Measured, Was It Managed? Quality Performance in the Age of COVID

During the first few months of the COVID-19 pandemic, CMS suspended in part quality measure reporting responsibilities. We wanted to know how the pandemic affected healthcare quality performance specifically.

In this blog post published nearly a year ago in Health Affairs, the authors argued that the pandemic would disrupt hospital quality reporting for “years to come.” They also said it would affect how well hospitals and health systems do in CMS-run performance-based payment programs.

What could throw off reporting? Well:

• PPE shortages
• Resource constraints
• Workforce issues
• Changes in patients’ typical acuity levels and care settings

The authors said the Hospital-Acquired Condition (HAC) program, the Value-Based Purchasing (VBP) Program and the Hospital Readmission Reduction Program (HRRP) were most likely to be affected by any skewed data.

So what did happen?

Quality Performance Went Down During COVID

We don’t know yet how readmission rates, mortality rates, spending and patient satisfaction will affect the Readmission, HAC and Value-Based Payment programs. Post-pandemic scores aren’t out.

We do know that a number of healthcare-associated infections (HAIs) went up in 2020, as we reported in this blog post last September.

Here are a couple of other data points for you.

• 2% of COVID patients discharged from a teaching hospital in 2020 went back within 30 days. More than 26% of the revisits were preventable.¹
• Patient mortality rose to 8.3% in 2020 from 7.8% in 2019.²
• Mortality rates of non-COVID patients were “substantially higher” in 2020 and 2021 than in 2019.³
  • Increases in the mortality rates of non-COVID patients were greater in “lower-quality hospitals” and hospitals with high numbers of COVID patients.³

Spending Per Patient Went Up During COVID

Spending per beneficiary jumped 9.4% in 2021.⁴ That’s more than double the 4.2% increase in 2019 and nearly seven times the 1.4% increase in 2020.

Patient Satisfaction Went Down During COVID

Medicare spent more money on beneficiaries in 2020 and 2021 than it did in 2019, but that investment didn’t show up in patient satisfaction scores.

Patient satisfaction scores dropped on nine of 10 HCAHPS measures in 2020 compared with 2019.² For example, 67% of patients gave hospitals the highest score on “responsiveness of hospital staff” in 2020, compared with 70% a year earlier. “Cleanliness of hospital environment” also came down three percentage points, from 76% to 73%.

The only patient satisfaction score to go up—and only by one percentage point, from 62% to 63%—was “quietness of hospital environment.” Could this be because of staffing issues and a lack of available visitor passes?

A couple more data points:

• Hospital and health systems’ Net Promoter Score dropped 12 points to 44 in December 2021 from 56 in April 2021.⁵
• From March 1, 2020, to July 31, 2021, the percentage of patients likely to recommend a hospital to their families and friends dropped 5%⁶

If patient satisfaction scores didn’t benefit from all the spending, who did?

Health system revenue and profitability went up during COVID

It seems counterintuitive, but revenue and profits actually rose for many prominent hospitals and health systems in 2020 and 2021, thanks to federal COVID relief funds and to investment income.

• Becker’s Hospital Review reported that a number of big health systems posted multibillion-dollar profits in 2020.⁷
• A year later, Becker’s ran virtually the same story, identifying seven health systems that enjoyed profits of more than $1 billion each in 2021.⁸
• In a follow-up story, Becker’s attributed the big profits at many health systems to investment income.⁹
• MedPAC, meanwhile, said hospitals’ all-payer total profit slid to 6.3% in 2020 from a record high of 7.6% in 2019 but “remained strong with the support of federal (COVID) relief funds.” Further, MedPAC said, “Preliminary data from 2021 suggest that hospitals’ all-payer operating margins exceeded pre-pandemic levels.”

Quality is Crucial

In summary, patient care fell, patient satisfaction fell, spending went up and hospital revenue went up.

The pandemic was so challenging for our healthcare system. The nation thinks of our healthcare heroes as those critical people at patients’ bedsides. And they are! But at Medisolv we witnessed firsthand how difficult the struggle was for our quality heroes too.

We see how difficult it was for them to manage the usual quality metrics during this time. They were the ones having to submit all the COIVD cases to state, federal and local governments day after day. Some of them had to return to bedside care. It was chaos.

It makes sense that quality of care slipped. That is why we believe so strongly in measuring the quality of care in order to assess whether we are appropriately caring for our patients. Because when you stop measuring it, performance can slip.

For quality managers, now is the time to dig into your data, measure your performance and make any changes necessary to maintain and improve your scores on your quality measures.

Sources:

1. https://www.jointcommissionjournal.com/article/S1553-7250(21)00213-0/fulltext
2. https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_SEC.pdf
3. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2789840
4. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected
5. https://nrchealth.com/new-report-unveils-nrc-healths-2022-health-predictions-on-shifting-consumer-behavior/
6. https://www.pressganey.com/about-us/news/patients-likelihood-to-recommend-healthcare
7. https://www.beckershospitalreview.com/finance/major-health-systems-report-1b-annual-profits.html
8. https://www.beckershospitalreview.com/finance/7-health-systems-reported-profits-over-1b-in-2021.html
9. https://www.beckershospitalreview.com/finance/investment-gains-a-main-driver-of-health-system-profits-in-2021.html