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CMS Hospital Star Ratings First Step in Effort to Improve Quality Measures

Kate Goodrich, MD, MHS
Patrick Conway, MD, MSc
October 4, 2016

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Kate Goodrich
Kate Goodrich, MD, MHS

Editor’s note: The opinions expressed by the authors do not necessarily reflect the opinions of the AAMC or its members.

On July 27, the Centers for Medicare and Medicaid Services (CMS) released the Overall Hospital Quality Star Ratings on the Hospital Compare website. This is a first step in a longer journey to improve the underlying measures and ratings system over time.

The Star Ratings methodology takes up to 64 existing quality measures already reported on Hospital Compare, summarizes them, then reports them in a unified rating of one to five stars. A hospital’s overall rating is calculated using only those measures for which data are available. This may include as few as nine or as many as 64 measures. The average is about 40 measures. Over the past decade, CMS has published information about the quality of care across five different health care settings that many families encounter. These easy-to-understand ratings are available online and empower people to compare and choose various types of facilities from nursing homes to home health agencies.

Patrick Conway
Patrick Conway, MD, MSc

The new Hospital Star Ratings will help patients and families learn about hospital quality, compare facilities side by side, and ask important questions about care quality. We realize this is only one piece of information for consumers and must be combined with other sources, including physician recommendations and consideration of the patient’s particular condition, circumstances, and preferences.

Developing the methodology

CMS developed the ratings to include quality measures for several aspects of care, from routine treatment for heart attacks and pneumonia to the occurrence of hospital-acquired infections. Specialized, cutting-edge services—for example, comprehensive cancer care or transplant programs—that hospitals such as academic medical centers (AMCs) provide are not reflected in these quality ratings. The methodology was developed with significant input from an expert panel that included hospital representatives, researchers, clinicians, and patients. The final methodology was refined after extensive public input.

Stakeholders at some hospital and health systems have expressed concern with the release of the new ratings. Some members of the academic medicine community believe hospitals that care for the most complex and socially vulnerable patients may not perform as well on the quality measures and therefore receive low ratings. These stakeholders have asked CMS to risk adjust quality measures or the Star Ratings themselves to account for patient socioeconomic status (SES).

We understand some hospitals have greater challenges than others in caring for patients at higher risk because of their SES. Stakeholders have suggested several ways CMS could consider patient SES in our payment programs. Suggestions have included risk adjusting certain quality measures for SES, stratifying hospitals based on patient demographics to allow comparison of similar facilities, and modifying payment policy to reduce penalties to hospitals that care for large numbers of patients of low SES. Of note is that hospitals treating large proportions of these vulnerable patients—such as safety net and teaching hospitals—were both high performing, receiving four or five stars, and low performing, receiving one or two stars. We observed, as did others, that major teaching hospitals had slightly lower average Star Ratings than other hospitals, and we want to engage with AMCs to further investigate this issue.

We realize this is only one piece of information for consumers and must be combined with other sources, including physician recommendations and consideration of the patient’s particular condition, circumstances, and preferences.

The 64 measures used in the Star Ratings are based on clinical guidelines and have undergone rigorous scientific review and testing. The vast majority are endorsed by the National Quality Forum (NQF), and many are already adjusted for clinical comorbidities. Traditionally, CMS has not included risk adjustment for SES in its payment programs as we have been concerned that doing so could potentially obscure disparities in quality of care. However, we recognize not accounting for the effect of patient SES may create disincentives for providers to serve patients with those risk factors, which could potentially reduce access to care.

We believe the decision to account for SES in payment programs should be driven by careful policy consideration and data analysis. CMS is working closely with NQF on a pilot project to evaluate the appropriateness of risk adjusting quality measures. We are committed to closely considering the pilot results, as well as the recommendations from a report that the Department of Health and Human Services (HHS) is scheduled to release Congress this fall. In addition, HHS is examining the effect of SES on quality and resource use measures in Medicare quality programs and will issue recommendations on how to account for such factors if a relationship is found between the two.

Next steps

CMS will continue to analyze the Star Ratings data and consider public feedback to make enhancements to the scoring methodology over time. At CMS, we have a long history of adjusting and enhancing our Star Ratings methodologies as we receive input from stakeholders and learn from implementation and ongoing data analysis. CMS made substantial updates to the Nursing Home Compare ratings in 2015, for example, and we plan to update the ratings on Dialysis Facility Compare this fall based on extensive stakeholder input.

In publishing the Overall Hospital Star Ratings last July, CMS confirmed our commitment to transparency and making performance information more understandable and relevant to consumers. We received numerous letters from national patient and consumer advocacy groups supporting the release of these ratings. In addition, researchers have found hospitals with higher ratings tend to have better outcomes and lower readmission rates. In the decade since we began posting the ratings, we have found that publicly available data drive improvement, better reporting, and more open access to quality information for patients.

We are committed to working closely with AMCs, hospitals, patients, and other stakeholders to continuously improve the Hospital Star Ratings. As doctors who have practiced in AMCs, we understand some of AMCs’ unique opportunities and challenges, as well as the important role these institutions play in clinical care, education, and research. We look forward to engaging with the AAMC and academic medicine community on this issue and many others. We have a shared goal of a health system that achieves better care, better health, and smarter spending.

Dr. Goodrich is the Director of the Center for Clinical Standards and Quality and Dr. Conway is the Chief Medical Officer and Deputy Administrator for Innovation and Quality, Centers for Medicare and Medicaid Services.

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