JOHNSON CITY, Tenn. (WJHL) — Two of Ballad Health’s three flagship hospitals are among 8% of hospitals nationwide with the lowest marks in the Centers for Medicare and Medicaid Services (CMS) most recent hospital “star ratings.”

Critics of Ballad have made much of the ratings on social media. Ballad leaders, as they have before, have taken aim at the ratings’ methodology.

Ballad leaders say the two “one star” hospitals — Johnson City Medical Center (JCMC) and Bristol Regional Medical Center (BRMC) — are exactly where they choose to send some of their most complex patients because they’re best equipped to deliver “better outcomes” than some Ballad facilities with higher star ratings.

To find out whether a hospital in the CMS rankings’ lowest standings could be a better option for high-level care than a ranking much higher, News Channel 11 found an expert. Dr. Karen Joynt Maddox.

The Washington University cardiologist has co-published numerous articles discussing the handful of hospital rating systems, which also include U.S. News and World Report, Leapfrog and Healthgrades. She said consumers often consult these systems to determine where to seek medical care.

“Like many things, there’s a kernel of truth and some of what CMS measures,” Joynt Maddox told News Channel 11. “It’s just much more complicated than can possibly be distilled down to one number.”

CMS uses 47 quality measures across five different categories to come up with its overall ratings.

Four categories account for 22% each of the total score: mortality (7 data points), safety of care (8 data points), readmission (11 data points) and patient experience (8 data points). The remaining 12% comes from 13 data points related to “timely and effective care.”

While she finds much to criticize in the CMS system, Joynt Maddox didn’t discount the rating entirely.

“One star is pretty bad and you have to do pretty bad on a lot of things,” she said. “I wouldn’t go to a one-star hospital. I’d think about a two-star hospital.”

Long a critic of the star system, Ballad CEO Alan Levine said the system’s biggest hospitals take its sickest patients. And because the CMS ratings only measure Medicare fee for service patient data, they’re measuring a narrow, poor, sick slice of its patient mix.

Levine’s chief clinical officer, Dr. Amit Vashist, put it this way:

“The star system is a very, very flawed methodology, we feel, because they are not weighing hospitals according to the severity of illness and the social determinants of health. Health care equity issues are not addressed on the star ratings.”

Joynt Maddox said that’s largely true. She said the star ratings’ process measures, which show whether a hospital delivers appropriate care, are things “we should hold hospitals accountable to, that we should make sure they measure them, we should make sure they do them.”

The other measures are outcome measures, which Joynt Maddox said are often influenced by socioeconomic and other factors largely out of a hospital’s control.

“Generally, the one star hospitals are a combination of hospitals without enough resources and patients without enough resources, and you can fix some of that, but not all of it,” she said.

Measures like hospital readmissions or diabetes control “are strongly influenced by how socially complex the patients are,” she said.

“Because most of these measures don’t account for social complexity, you end up with a real mix of some metrics that reflect what hospitals are doing and some metrics that really reflect more of the population they’re serving.”

“I think it’s fair to ask all hospitals to do more and to do better, but to expect that hospitals are going to be able to get the same outcomes with very different groups of patients, people are not widgets, and they don’t act that way. Distilling everything down to a small set of metrics that are moving more and more toward outcomes, I don’t think really captures the complexity of what hospitals are doing.”

JCMC and BRMC both received one star out of a possible five when CMS released its annual ratings July 28. Ballad’s other large medical center, Holston Valley, got two stars.

Its smaller hospitals, Indian Path in Kingsport and Sycamore Shoals in Elizabethton, each got four stars, with Franklin Woods, a smaller Johnson City hospital, getting three stars. Ballad’s Smyth County in Marion, Va., was rated five stars.

Vashist and Dr. Clay Runnels, Ballad’s chief physician executive, told News Channel 11 that JCMC, BRMC and Holston Valley are exactly the places Ballad’s sickest and most difficult patients should be going, and that it’s where the system sends them.

“They have an inordinate number of those complex medical patients, particularly the fee for service Medicare patients, and that’s by design because that’s where we want them and they have better outcomes there,” Runnels said.

Joynt Maddox said that approach does make sense. Health systems “need to help patients sort where they need to be.”

“Someone walks into their local hospital having a major heart attack and the hospital they walk into doesn’t have a cardiac cath lab, you send them someplace where they can get the care they need, that’s your medical duty.”

Joynt Maddox said the CMS ratings risk adjustment “does a better job of accounting for medical complexity than social complexity.” But Runnels said BRMC’s U.S. News and World Report rankings show it high-performing in five important measures— including stroke, heart failure, heart attack and diabetes. JCMC ranks high in four measures including lung cancer surgery, stroke and knee replacement.

“Multiple entities including the Joint Commission, and Blue Cross Blue Shield, have certified our facilities as high quality for treatment of things like coronary disease and heart attack and stroke,” Runnels said. “To me that’s a much more valuable piece of information when people are making their decisions.”

U.S. News and World Report is a ranking system that Joynt Maddox praises for adjusting for social factors far better than she said CMS does.

For her part, Joynt Maddox said the CMS ratings have a tendency to create perverse incentives, though the agency is working to address that.

“Historically, all of the quality measures and all of the programs were very short timeframes, with bad risk adjustment and no accounting for social risk,” she said. That could drive hospitals that had the option to find the healthiest people and serve them.

“Admit lower risk people because that just makes everything look better, right? And then a bunch of people who aren’t going to have bad outcomes, that makes you look even better. It makes you makes you make a lot of money.”

That type of model didn’t decrease utilization and “it didn’t lead to focusing on the sickest patients,” Joynt Maddox said. “I would say to give credit where credit is due, everyone is trying to change what they’re doing.”

She does her medical work in a 13-hospital system centered in St. Louis. She said the group’s suburban hospitals are typically four or five-star, and “our rural poor hospital and urban poor hospitals have been twos.”

“I wouldn’t go to a one-star hospital without understanding more about what was going on and I’d think twice about a two-star hospital,” she said. “Not because I think the doctors are bad people, but because it probably reflects a combination of not enough resources and underresourced patients.”