Problems outside local hospitals' control may be a reason why a recent national performance survey ranked Hawai'i in the bottom fifth nationally.

Hawai'i hospital executives said they believe local medical centers are safer and have better operations than what was indicated in the recent Solucient Top 100 study, which ranked the state among the bottom 20 percent in performance. The study examined hospitals in terms of clinical quality, efficiency, finances and consumer responsiveness.

"There is a deep, passionate, mission-driven commitment to quality care in this state," said Kevin Roberts, president and chief executive officer of Castle Medical Center. "We're not asleep at the wheel when it comes to quality."

After reviewing the study, the executives said there are a number of factors that pull down the state in Solucient's and other rankings, not the least of which is the state's long-term care bed crisis. According to an AARP ranking, Hawai'i has the 48th-lowest ratio of nursing facility beds per 1,000 residents in the country.

That means hospitals frequently must retain patients who normally would be discharged to nursing facilities remain in hospital beds until a long-term care opening occurs. One day earlier this month there 55 patients "wait-listed" for nursing homes at the Queen's Medical Center and 100 at the Hawaii Health Systems Corp.'s two largest hospitals.

Last year, the Healthcare Association of Hawaii released a report saying on average there were about 180 patients waiting in hospitals each day in 2005 for beds at long-term care facilities. This can weigh financially on hospitals since Medicare patients are given care without additional cost until they can be discharged, while Medicaid patient payments don't cover costs.

The Healthcare Association estimates the statewide cost for these patients at $110 million in 2005, which probably would have hurt Hawai'i's ranking because Solucient's benchmarking included looking at profit, cash-to-debt ratios and expense per discharge on an adjusted basis.

Hawai'i's hospitals also had $108.2 million of charity care and bad debt in 2006. That contributes to a situation where payments for services at local hospitals haven't covered costs in every year since the turn of the millennium.

"We do have some unique issues here," said Thomas Driskill Jr., president and chief executive officer of the Hawaii Health Systems Corp., operator of most hospitals on the Neighbor Islands. That includes the state being one of two in the nation that don't get Medicare payments adjusted higher under the disproportionate share hospital program.

"When you see a lot of Medicaid patients, you lose money," Driskill said.

But the waitlist issue causes problems beyond the financial issues, executives contend. They said it affects several other categories Solucient studied, including length of stay and growth in patient volume. Of the 11 states and the District of Columbia in the bottom rung of Solucient's ranking, five are among the worst in terms of nursing beds.

Shortages of hospice beds also means that people who might die elsewhere are passing away at medical centers. That impacts Hawai'i when compared to mortality rates nationally, executives said.

"We get hurt for that in a way," said Dr. Todd Seto, director of Queen's Medical Center's Center for Best Healthcare Practices. Elsewhere, "those patients would die outside the hospital."

STUDY SET BENCHMARKS

Executives said the problems were a reason that Hawai'i ranked 43rd in a patient care study by Health Grades Inc. in 2005. Jean Chenoweth, author of the Solucient study, said the long-term-care bed shortage could have been a contributing factor to the state's ranking.

"It's quite possible that that is a problem," Chenoweth said. "It may be that Hawai'i does have a real problem with length of stay."

The Solucient study did not break out ratings for individual hospitals. The study's goal is to identify benchmark performances of top hospitals by measuring them in nine areas, allowing hospital executives to see how their financial and healthcare management stacks up against colleagues elsewhere. The study excludes hospitals with fewer than 26 beds, plus pediatric, specialty and veterans hospitals.

Other factors unique to Hawai'i may have contributed to the poor showing in studies. That includes a shortage of nurses that raises costs and feeds into problems with a lack of long-term-care beds and health problems afflicting certain ethnic groups that are more prevalent in the state. Executives acknowledged that not enough local doctors are taking time to code patient reports so that all health problems show on Medicare reports used by researchers producing reports.

For example, a doctor may have a longtime patient who has just quit smoking and has a bleeding ulcer, but doesn't put that information into a report when treating the patient for a heart attack.

Seto said it doesn't affect the quality of care, but may make the hospital look bad in reports when researchers check whether the patient was asked about smoking or given aspirin to help with the heart problem.

He said hospitals need to do a better job getting physicians to fill out reports more completely.

Executives were also critical of Solucient's overall study, noting that many of the top names in healthcare didn't make its list of top 100 medical centers this year. This included those at Duke, Johns Hopkins and Stanford universities. Chenoweth said some of these and other top hospitals such as the Cleveland and Mayo clinics, have been cited in its reports multiple times.

She said part of the reason for the study is to help hospital leadership identify problems and that it appeared the Hawai'i hospitals had been aware of or had identified the issues dragging down the ranking.

"That's precisely what public reporting has done across the country," she said. "It has allowed the industry to step forward to identify those barriers to higher performance and articulate them as a public issue."

Said Driskill, "We provide safe, quality care. We won't provide sub-standard care."

Reach Greg Wiles at gwiles@honoluluadvertiser.com.