CMS’ Hospital Star Ratings:
April 08, 2016 | By: Andy Carter
7 narrow measure domains and an elephant?
You know the fable. A group of blind men touch different parts of an elephant. When they compare their findings, they fall to arguing. Is the elephant a pillar, a rope, a tree branch, a wall, a pipe?
The Centers for Medicare & Medicaid Services’ (CMS) quest to give hospitals star ratings based on approximately 60 different measures related to seven narrow domains of hospital care runs some of the same risks. Summarizing the relative quality of a hospital into a single rating—five stars for the best-performing hospitals, one star for the worst—is a tricky business.
In the next few weeks, CMS plans to unveil the new ratings at Hospital Compare. About half of the hospitals rated will be in the middle, with three stars. A few (2.4%) will get five stars. Nearly 4 percent will get one star.
Why CMS is doing this is easy to understand. As hospital rating systems proliferate, the nation’s leading purchaser of hospital and health care services wants to give a confused public a quick, simple, easy way to judge a hospital’s quality.
It’s the “how” that could mislead health care consumers and frustrate hospitals.
The limits of Hospital Compare: mostly medicare patients…
CMS is basing star ratings on the information at hand: hospital quality and performance data displayed at the Hospital Compare website.
Hospital Compare data has evolved over time since its beginnings in 2002 as the Hospital Quality Alliance. Today’s measure set largely focuses on important but relatively narrow aspects of hospital services (such as care for heart attack, stroke, and pneumonia) that affect mainly older adults, and patient experience data.
Hospital Compare’s crucial outcomes data—how did patients fare?—comes only from Medicare fee-for-service patents, who represent less than a third of Pennsylvania hospitals’ total patients.
…And what about sociodemographic factors?
Even if we accept the limited nature of Hospital Compare’s data set, is hospital performance fairly assessed within these constraints?
“No” is the answer suggested by an expert panel convened by National Quality Forum (NQF). In 2014, the panel concluded that performance measures used in public reporting (like those on Hospital Compare) should be adjusted for sociodemographic status.
The panel recognized that factors far outside the control of doctors or hospitals—patients’ income, housing, and education—can significantly affect patient health, health care, and hospital performance scores.
NQF is assessing the impact of panel’s recommendations, and, to date, Hospital Compare measures and ratings lack any such risk adjustment. Meanwhile, hospitals that serve disadvantaged communities are at a disadvantage when it comes to their Hospital Compare performance scores.
Missouri Hospital Association’s recent column reviews CMS’s evolving stance on sociodemographic status risk adjustment. (Spoiler alert: after years of advocacy by insurers, star ratings for Medicare Advantage plans are risk-adjusted for socioeconomic factors. CMS tacitly acknowledged that sociodemographic factors can pose challenges for hospitals when it released guidance to help hospitals reduce readmissions for vulnerable patients. But no sociodemographic risk adjustment for data on Hospital Compare … yet.)
Quality ratings of limited value?
Only a few Hospital Compare measures apply to hospital patients overall. As a result, consumers looking to deliver their babies, defeat cancer, or manage chronic conditions are better off checking sources other than Hospital Compare.
Despite the limitations of CMS star ratings, the hospital community supports the public reporting of hospital and health care quality and performance information. But we want this information to be as useful and understandable as possible for consumers.
We are pressing CMS and others to improve performance measures and ratings so that they accurately reflect the quality and value of health care services. Adjusting CMS Hospital Compare measures and ratings for sociodemographic status would be a good start.
Longer term, we want to work together with government, insurers, and other health care stakeholders to establish a standard set of evidence-based measurements that can inform health care quality improvement, value-based purchasing and payment, and consumer decision-making. Currently Hospital Compare has some, but certainly not all, of the metrics we need.
Better ways to measure—and move—the beast
In many ways, hospitals and health systems in Pennsylvania are taking on the challenge of a generation. We seek to improve our state’s lagging health; increase the quality, safety, and efficiency of health care; and reduce per capita health care spending (in part by keeping Pennsylvanians healthy and out of the hospital).
To get there—and to measure our progress along the way—health care providers, public and private payers, and other stakeholders must get on the same page about what performance metrics we track and why.
This is a daunting task, given the complexity in how we deliver and pay for health care. (In some ways health care really is a beast—extraordinarily powerful, and especially adept at delivering the very latest, very best medical treatments and interventions.)
Leading health care policy organizations have recognized the need for better ways to assess the effectiveness or our health and health care. The Institute of Medicine in collaboration with Blue Shield of California, Robert Wood Johnson Foundation, and others, have proposed 15 standardized measure categories with which to assess America’s progress in four main domains: healthy people, care quality, lower cost, and engaged people.
The Hospital & Healthsystem Association of Pennsylvania is doing its part. We are looking for ways to foster consensus on meaningful performance measures in our state.
We’ve identified a potential first step: the framework and assessment metrics for value-based payment in Pennsylvania’s Medicaid managed care program, called HealthChoices. We are advocating that government, insurers, and hospitals work together to define a standard approach and measure set with which to assess and incentivize effective, high-quality care for patients with Medicaid coverage.
One meaningful measure set for the 15+ health insurance plans and 220+ hospitals that serve nearly 2.6 million Medicaid patients in Pennsylvania?
That’s a wonderful opportunity to measure the beast fairly, accurately, and efficiently, and get it moving even further and faster toward a Healthy Pennsylvania.