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Second Opinion

News and perspectives from AAMC's Executive Vice President

Second Opinion Podcasts

An occasional series on policy issues important to medical schools and teaching hospitals, featuring AAMC Executive Vice President, Atul Grover, M.D., Ph.D.

June 8, 2016

Being the best is something that drives most of us from a very early age, and the urge to be the best or be associated with the best extends into adulthood. With health care, it can take on life-and-death significance. We know instinctively that not all health care providers are equal; but health care is infinitely complex, and identifying “the best” is hard.

It’s commendable that the Centers for Medicare and Medicaid Services (CMS) strives to produce consumer-friendly measurement tools. In recent years, CMS has rolled out Five Star Ratings for nursing homes External Link and managed care plans, and for hospital performance on patient experience surveys. CMS uses dozens of different measures to assign stars to an institution―one for worst, five for best.

The AAMC and the nation’s medical schools and teaching hospitals support public reporting of data and the use of star ratings for groups of measures, such as mortality and readmissions. We think such a system would be valuable for consumers. 

Soon, however, CMS plans to change Hospital Compare to include a single composite star rating measure for each institution. We know from experience that efforts to rank hospitals are challenging, and simplifying complex information for consumers to use for making informed choices about patient care is difficult. Unfortunately, CMS has not yet gotten it quite right – and the consequences are serious for patients and the hospitals that serve them.

Taking into account both our experience with quality measures and our commitment to offering consumers understandable and fair data to use for comparing providers, we strongly urged  delaying implementation of CMS’s new composite star rating system for hospitals to give CMS the opportunity to revise the measures the system uses. To its credit, in April, CMS agreed to this delay. External Link

CMS doesn’t adjust the rating system to account for hospitals that treat a high proportion of complex cases or a large number of socioeconomically disadvantaged patients. Rigorous reviews External Link of hospital readmission rates have proven that social factors outside of a hospital’s control have a large impact on readmission rates, a nuance masked by simply giving a hospital a low star rating. Further, hospitals that take on complex cases from other hospitals regularly have higher mortality rates than their smaller, community hospital peers. Without adjusting for these factors, those hospitals best equipped to respond to emergencies and complexities are punished for their expertise.  

It’s not just a conceptual problem. Although CMS has not yet published its ratings data or methodology, it gave affected hospitals a preview of the unpublished ratings, and many observers have found them troubling. The ratings suggest that a large number of the nation’s most prestigious, mission-driven medical centers—major teaching hospitals and public hospitals—would score poorly, while hospitals that treat less-diverse patient populations or provide less-complex and less-cutting-edge service would receive implausibly high ratings. Preeminent experts in hospital evaluation agree that the preliminary results are simply not credible External Link. Consumers will be confused, not aided, if CMS’s new star ratings provide the opposite verdict on hospital quality to nearly all other hospital ranking systems.

The rating system is clearly not ready for prime time. We need to see CMS’s data, analysis, and revised methodology to learn why the system doesn’t work and how to fix it. Otherwise, the star ratings will have no value to consumers and may mislead them towards substandard care.

The hospital community was united in urging CMS to delay implementation and disclose its detailed methodology; 60 U.S. senators and 225 U.S. representatives External Link made the same request. When it announced the delay in April, CMS said it would carefully evaluate its data to see if the current methodology disproportionately affects hospitals serving the most complex or underserved patients. So far that examination has not been released, nor has the Agency released the data necessary to evaluate any changes. Hospitals understand the need for rigor, but also insist on transparency. CMS must not release the composite star ratings publicly until it releases the detailed methodology and analysis it has promised and provides sufficient time for review.

Consumers deserve the right to compare hospitals to find the best care; however, they can only do this if the data are fair and accurate. Therefore, CMS should take the following steps: increase the level of transparency by releasing the data and detailed methodology behind the ratings and ensure that the ratings are based on fair quality metrics that do not disproportionately affect certain types of hospitals.   

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About the Author

Atul Grover, MD, PhD AAMC Executive Vice President

Atul Grover, MD, PhD
AAMC Executive Vice President

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For More Information

Peters Willson
Sr. Specialist, Policy and Constituency Issues
Telephone: 202-862-6029