Mission Hospital’s Leapfrog, Healthgrade scores and rankings don’t tell the whole story, draft report says

A draft of a study on HCA Healthcare’s purchase of Mission Health addresses a significant question: How does Mission Hospital get such high marks from hospital ratings companies as it faces the most severe sanction the federal government can levy? 

Mission Hospital received an “A” safety grade from The Leapfrog Group in fall 2023 and made Healthgrades’ list of America’s 50 Best Hospitals in January — even as federal investigators were determining that the quality of care at Mission was so bad that it had “caused — or is likely to cause — serious injury, harm, impairment or death to a patient.” 

Leapfrog granted Mission Hospital its highest “A” safety grade even though Mission did not submit health or safety data to the semiannual survey. 

Healthgrades named Mission Hospital one of the 50 Best Hospitals in America despite ranking it below the national average in every one of its measures of patient care, from patient satisfaction to staff responsiveness and cleanliness.  Healthgrades also gave Mission Hospital its 2023 “Patient Safety Excellence Award” — honors that Mission and HCA advertised even as it was preparing proposed remedies for the serious problems federal and state health inspectors had documented at the facility. 

HCA’s website currently states: “Fact: The quality of care at Mission Hospital is among the best in the nation. We are proud to be recognized by Healthgrades as one of America’s 50 Best Hospitals and we just received our 5th consecutive Leapfrog Hospital Safety Grade ‘A’.”

On Dec. 19, after an on-site investigation, the North Carolina Department of Health and Human Services recommended to the U.S. Centers for Medicare & Medicaid Services that Mission be put in “immediate jeopardy” for nine deficiencies within the previous 19 months. 

The NCDHHS action came five days after North Carolina Attorney General Josh Stein filed a lawsuit against HCA and Mission. Stein, a Democratic gubernatorial candidate, alleged they have not lived up to their commitments to maintain emergency services and cancer care.

On Feb.1, CMS notified Mission CEO Chad Patrick that the hospital had until Feb. 24 to fix numerous deficiencies in care or lose its Medicare & Medicaid funding, which would threaten its financial viability. 

A 12-page working draft of a report — written by Mark A. Hall, a Wake Forest professor of law and public health, and obtained by Asheville Watchdog — raises skepticism about the Leapfrog and Healthgrades rankings.

“Even crediting Mission with the full benefit of its favorable ratings under HCA, it is clear that Mission is no longer at the level of excellence it had achieved prior to HCA,” the draft report, titled “Mission Hospital’s Quality Ratings Following HCA’s Acquisition,” states. “Patients’ ratings of their hospital experience have plummeted to the lowest level, and Mission no longer regularly scores at the highest levels under the more rigorous and widely respected systems that rate overall quality.”

It does note that “[s]ome objective measures of quality and patient safety are still high, however, and others are still respectable.”

According to CMS data, 54 percent of Mission patients would “definitely recommend” the hospital to others — 16 percent lower than the national average for other hospitals. Fifty-eight percent of respondents to the Hospital Consumer Assessment of Healthcare Providers and Systems survey rated Mission a 9 or 10 on a 10-point scale of quality of care, 11 percent below the national average.

As Asheville Watchdog reported in April 2023 following that year’s “50 Best Hospitals” announcement, Leapfrog and Healthgrades ratings provide far from the full picture when it comes to hospital performance. Both companies charge hospitals a fee to participate in the ratings system. But, moreover, they are limited in scope, and medical experts interviewed by The Watchdog last year doubted the ratings truly inform patients.

“Assessing the many facets of hospital quality reminds me of the parable about the blind men and the elephant, each of whom thinks the beast is something different according to what they are sensing,” Hall told The Watchdog last week. “In this report, I aim to give a more complete picture than one that is blinded to the less positive indicators.” 

When it was a nonprofit operation before HCA’s 2019 purchase, Mission was once one of the highest quality hospitals in the country, a status that numerous measures supported, according to the report.

Researchers from the Economic and Social Research Institute, a nonprofit that conducts research and policy analysis in health care, concluded in a 2004 study that “Mission [was] an excellent example of how a variety of factors can come together to promote quality of care in a large institution … [because] the drive to do whatever it takes to provide the best possible care seems to permeate the organization, from the Board to the executive levels to the bedside.” 

In late 2023, however, sources interviewed for Hall’s report said that, “despite plummeting patient ratings and diminished quality metrics, HCA has no real incentive to do better than average, acceptable, or enough to ‘stay out of trouble,’ considering that doing better ‘does not matter’ if patients and physicians ‘have nowhere else to go.’”

One unidentified physician interviewed for the report said the situation under HCA ownership feels “like juggling eggs, with more being thrown at you all the time, and having to catch them just before they hit the floor. So far [we] have been able to do that, but at some point …”

HCA and Mission spokesperson Nancy Lindell did not respond to a series of questions about details in the report, but said it was “neither a serious nor an impartial ‘study’ and it does not justify comment or response.  

“It was funded by a group that is funding litigation against Mission Health, and given the financial backing of that group, it is not surprising that the ‘study’ is critical of Mission Health,” Lindell said.

She did not respond when asked for specifics about the litigation.

Hall, a member of the National Academy of Medicine, is a leading scholar on health care law, public policy, and bioethics, and the author or editor of 20 books. He recently wrote another draft report that said HCA has significantly decreased charity care for lower-income Mission patients since its purchase of the hospital.

He is an independent academic researcher whose work is funded through an Arnold Ventures grant to Wake Forest University. 

Arnold Ventures is a philanthropic group headquartered in Houston “working to improve the lives of all Americans by pursuing evidence-based solutions to our nation’s most pressing problems. We fund research to better understand the root causes of broken systems that limit opportunity and create injustice,” according to its website.

Arnold Ventures is helping to fund Fairmark Partners — a group pursuing antitrust lawsuits against “hospital behemoths in Wisconsin, Connecticut, and North Carolina,” according to the group’s website. Attorneys at Fairmark are representing plaintiffs in an western North Carolina antitrust lawsuit against HCA and Mission Hospital.

Why are Healthgrades and Leapfrog ratings so high?

Noting the hospital’s recent immediate jeopardy sanction, the draft report indicates Leapfrog and Healthgrades don’t include some data and facts that could draw a more complete picture of what’s going on inside Mission.

Hall’s report describes Healthgrades ranking of Mission as one of the country’s top 50 hospitals  – the only such ranking of a hospital in North Carolina – as “counterintuitive.”

“One explanation is the long eight-year “look-back” period that Healthgrades uses to classify and rank hospitals,” the report states. “This expanded window means that Mission’s current ranking is still based in significant part on how it performed for several years prior to HCA’s acquisition.”

Additionally, Healthgrades ranks Mission high based largely on surgical procedures and a handful of other measures rather than on the array of hospital care delivered by nurses, hospitalists, and other clinicians, the report states. 

“Healthgrades’ ratings indicate that, under HCA, Mission has maintained top performance selectively rather than across the board,” the report states. 

Asked about the report’s analysis of the Healthgrades ranking, the rating company’s chief medical officer, Dr. Brad Bowman, said the group “rated hospital inpatient admissions based on objective clinical outcomes data that does not include emergency room visits,” to create the top 50 list. 

“The focus of the deficiencies that HCA Mission Hospital received were tied to ED [Emergency Department] care. ER patients that experience delays in triage and care are not in the CMS inpatient data set used by Healthgrades for America’s Best Hospitals,” Bowman said.

The organization measures only objective clinical outcomes (medical complications and patient deaths) to compile ratings, Bowman added.

“Healthgrades’ focus on clinical performance differs from other ratings systems that look at a matrix of measures to assess hospital performance — some including reputation-based surveys, others using more fluid methodologies that include ‘peer grouping’ and academic and network affiliation adjustments,” Bowman said. “Healthgrades’ transparent methodology remains committed to focusing on what matters most to patients, families, communities, and providers — clinical outcomes.”

Leapfrog’s system is also limited in scope. 

While it relies heavily on federal data, it does not include data reflecting patients’ views or experiences, which have worsened since the HCA purchase, according to the report. 

“What we have in the hospital safety grade is really a mix of a handful of patient safety focused measures from the LeapFrog hospital survey,”  Leapfrog’s Vice President of Health Care Ratings Missy Danforth told The Watchdog. “And also, some patient experience measures from CMS. And then some patient safety outcome measures.”

Leapfrog also allows hospitals to make strategic decisions to avoid reporting certain data elements that might be unfavorable, specifically, allowing hospitals to opt into a self-reporting survey where it can provide details about things like patient-centered care, preventing patient harm, and health care-associated infections.

Mission did not submit a survey in 2023, according to Danforth. It did in 2022, 2021, and in 2020 results submitted in 2019 were carried over because of COVID-19, which was not unique to Mission.

When asked why Mission did not participate in the 2023 survey, Lindell, the Mission spokesperson, said, “The healthcare industry has seen an increase in surveys asking for inputs that don’t always focus on what matters most – clinical outcomes.

“Therefore, we have paused our submissions to Leapfrog until we determine if their measures correlate with performance in purely patient outcomes. Given that HCA Healthcare has historically been rated highly by Leapfrog, the decision to pause our submissions was a difficult one; however, we believe it is unwise to spend the precious time of our hospital clinical leaders to complete a lengthy survey and, instead, will rely on publicly available data.”

Mission received an “A” grade for the fall and spring in 2023; an “A” for the fall and spring of 2022; an “A” in the fall of 2021 and a “B” in the spring of 2021; an “A” in the fall of 2020 and a “B” in the spring of 2020; and a “C” in the fall of 2019 and an “B” in the spring of 2019.

More than 2,300 hospitals do a voluntary survey each year, Danforth said.

Even though Mission did not submit a survey for 2023, Leapfrog used its response from 2022 to create the latest “A” grade. This will not continue if Mission continues to not complete a survey, Danforth said.

Other ratings don’t look good

Other ratings of Mission have not been so positive over the past five years, according to the report.

“Most strikingly, Mission’s patient experience ratings have plummeted under HCA,” the report states, referring to Business North Carolina rankings of the state’s hospitals based on a systematic federal survey of the percentage of patients who would recommend the hospital to others. “In the six years prior to HCA’s acquisition, Mission Hospital’s state rankings ranged from 3rd to 7th on this recommend-to-others indicator, but during the first year under HCA (2019), Mission’s patient-experience ranking suddenly dropped to a statewide tie for 18th to 23rd,” the report states.

Business North Carolina bases its rankings on data collected and reported by the federal government and turned into a star rating system, with five stars representing the highest likelihood of patients recommending a hospital. 

“From 2014-2018, Mission Hospital averaged four stars. In 2019, however, the first year under HCA, this patient rating… dropped to two stars, and remained there, until 2022, when it dropped to one star,” the report states.

CMS also has an overall five-star system separate from the patient survey. In the spring of 2021, which is the first year relevant data fell primarily under HCA management, the federal government downgraded Mission Hospital from five stars to four, according to the report.

“Four stars is still respectable, but it puts Mission in roughly the top half of rated hospitals in North Carolina, rather than the very top tier,” the report states. About 10 percent of hospitals nationally receive five stars, according to CMS. 

“In the five years prior to HCA’s acquisition, US News ranked Mission from 5th to 7th statewide for overall quality,” the report states. “The first two years under HCA, when most underlying data predated the acquisition, U.S. News continued to rank Mission in the top 10 statewide. But since 2021, Mission has fallen out of the top 10 in the state and it currently ranks in a 4-way tie for 12th to 15th. While this is a respectable ranking, it is a distinct step down from the very top ranks that Mission occupied prior to HCA.”

Another rating system is Premier’s PINC AI hospital data platform, which publishes an annual top 100 and top 50 hospitals report. The rating system was bought from IBM Watson Health, which in 2018 concluded Mission Health was one of the top 15 systems in the nation.

Mission no longer appears on PINC AI’s 2023 top 100 hospital list or on its top 50 cardiovascular hospitals list.

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Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org. The Watchdog’s reporting is made possible by donations from the community. To show your support for this vital public service go to avlwatchdog.org/donate.