As the Centers for Medicare & Medicaid Services mulls new payment rules for hospitals, its leaders should consult a crucial concept from the book that made Donald Trump famous, then apply it to quality and safety regulations. Also, Archimedes.
The concept they have in common is leverage.
In The Art of the Deal, then-real-estate-magnate-and-now-president Trump writes, “Leverage is having something the other guy wants.” It is, he emphasizes, “the biggest strength you can have.” Since CMS spends over $1 trillion on health care each year, it has the unique leverage of something everyone wants.
The agency should apply that leverage in two ways as it finalizes the inpatient prospective payment system draft regulations, whose comment period closed June 10. First, CMS should strengthen requirements that can make care better, safer and more cost-effective. Second, it should move decisively to give patients themselves more direct leverage in the form of actionable information.
Safety First
Approximately one in four hospitalized adults suffers a patient safety problem of some sort, according to the Department of Health and Human Services’ Office of Inspector General. Assessing the human impact, the Leapfrog Group has estimated that 160,000 Americans died avoidable deaths in 2018 from only the types of medical errors addressed in its voluntary standards. While there’s a wide range of estimates of the financial impact of error, hospital-acquired infections alone are estimated to cost up to $45 billion.
CMS has already established a timetable for implementing Patient Safety Structural Measures, but those measures’ use could be amended or even eliminated due to objections to its impact on payment that some organizations are still surfacing even in this current rule-making cycle. At first glance, the requirements seem rudimentary. For instance, hospitals must merely “attest” to elementary actions such as addressing safety topics at governing board meetings and showing a “leadership commitment to eliminating preventable harm.” Reporting begins this year, though results won’t be public until next fall. Hospitals that don’t submit data can have their Medicare pay reduced, albeit not until Oct. 1, 2027.
Do the feds really need leverage to prompt such basic actions? Unfortunately, a survey by the hospitals’ own trade group, the American Hospital Association, found that only 50 percent of hospital boards had quality as one of their priorities. Even more worrisome, 52% of respondent to the 2022 AHRQ Survey of Patient Safety Culture survey said “hospital management seems interested in patient safety only after an adverse event happens.”
Toughen Transparency Rules
CMS should also demand more, and more useful, hospital transparency. The agency is proposing a couple of steps. It wants inpatient quality data on its Compare website to include data on Medicare Advantage beneficiaries, once a small slice of Medicare but now 54% of all those enrolled. The agency also wants to require cancer hospitals, previously exempt from reporting, to now publicly report quality measures. Comments submitted by Patients for Patient Safety US praised that proposal as a way to “better support patient and family decision-making about where to seek intensive cancer care.” (Disclosure: I’m a PFPS US member.)
But CMS can get patients an even better deal. The Leapfrog Group’s comments to CMS called out meaningless transparency (my adjective, not theirs) in which the Compare website data is statistically adjusted so that 90% of hospitals seem no different than the national average. This, the group wrote, “sends a dangerous message to consumers [that]
all hospitals are the same,” even though “the difference can mean life or death.”
In my own comments, I urged CMS to stop displaying data in a complex manner that confuses consumers. I advocated switching instead to a “radical” transparency based on Maslow’s Hierarchy of Needs, a framing that resonates emotionally. An actionable framework I developed with Johns Hopkins associate professor Matt Austin mapped common hospital quality measures into three Maslow categories, with a “drill down” possible via the web for more detail. Those categories were: “Will I be safe?” (for Maslow, that correlates with the basic need for survival and safety from harm); “Will I be heard?” (in Maslow’s hierarchy, the need for esteem and respect from others); and “Will I be able to lead my best life?” (self-actualization).
Meanwhile, Leapfrog urged CMS to improve data usefulness by reporting results from federal programs using the actual name of the brick-and-mortar hospital, not its CMS Certification Number. I’ve urged something similar in regard to Medicare Advantage star ratings,, which aren’t part of the current regulatory draft. Right now, star ratings of health plan quality aren’t based on what a local plan does, which most consumers would assume, but on the CMS plan contract number, which at times applies to plans located across the entire country.
Leapfrog also advocated eliminating the exemption from public reporting that, in addition to cancer hospitals, applies to critical access hospitals, pediatric hospitals, hospitals in U.S. territories and other facilities. Every patient, Leapfrog wrote, deserves “the same safety, quality and resource use information.”
Empower Patients
Separately, Patients for Patient Safety urged CMS to fix a “foundational flaw” undermining accurate patient safety data by providing patients with what amounts to a powerful lever. Current error reporting relies on hospitals self-reproting; that has resulted in only about 5% of harm being reported, according to research cited by Patients for Patient Safety . Patients “notice things others miss,” Patients for Patient Safety pointed out, yet “we are systematically excluded from harm reporting systems.” The group called for CMS to empower patients and families to directly report harm.
As I noted in a previous Forbes column, two goals CMS administrator Dr. Mehmet Oz immediately set out when he took office were “empowering the American people” to better manage their health and holding providers “accountable for health outcomes.” The quality and safety rules supported by activists represent a golden opportunity to take giant steps in that direction.
Finally, there’s Archimdes. The ancient Greek mathematician famously said of leverage, “Give me a lever long enough and a fulcrum on which to place it, and I shall move the world.” By comparison, CMS has only to use the powerful leverage of its quality and safety regulations to move the American health care system.
As President Trump described leverage in his book, “Don’t do deals without it.”
