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Get Ready for Medicare's 5-Star Hospital Ratings

 |  By cclark@healthleadersmedia.com  
   April 03, 2014

CMS intends to implement a five-star rating system on all of its web sites that display comparative quality information for providers. Stars are nice, but precision, in the form of detailed quality data, must remain public for quality to improve.

I thought I was on to a big hush-hush secret. On Monday I began making inquiries to my sources in Washington. I'd heard that Medicare was making plans to rank hospitals using a five-star system. Five stars. Wow.

A public affairs official with the Centers for Medicare & Medicaid Services called it a "rumor" and said no such change was planned, at least not "in the near future." I was told that my sources were confused.

But after nearly 30 e-mails between CMS and me over the last three days, I've finally received confirmation: Medicare does intend to apply its Five-Star Rating System to some 4,000 Medicare-eligible acute care facilities in a Hospital Compare update, and "maybe" as early as this December.

Maybe to you and me that's not the "near future," but in a hospital leader's world, it's almost tomorrow.

Just like CMS gives stars to nursing homes, Medicare health plans with Part B coverage, Medicare Advantage plans, physician group practices and accountable care organizations on Physician Compareto mark their comparative performance on a variety of quality measures, hospitals too will be scored with one to five little green stars.

In fact, CMS intends to move to a five star-rating system for all of the sites where it displays quality information for providers, that is all of its "Compare" sites, "with a goal of full transition to star ratings by 2016," CMS public affairs specialist Don McLeod confirmed in an e-mail. Dialysis centers and home health care agencies, too will get stars by 2016.

"It's no big secret, but we are moving slowly and there's no big announcement yet," he wrote.

Many Questions
Of course much about how CMS will apply the five stars remains under wraps. Or is still undecided. So of course I have questions.

For example, will 20% of all hospitals get either one, two, three, four, or five stars, indicating their ranking order, even if a three-star achiever is essentially equivalent to a two-star achiever? Or does CMS intend to set performance thresholds and group hospitals in buckets, depending on their scores?

CMS could say that all hospitals that score below 20% in performance would get the lowest ranking of one star, but if only 10 of the 4,000 hospitals fell into that low poor performer's bucket, only 10 would get one star.

That, in my opinion, would be too bad, because that information is really useful only for consumers, payers, and competitors who might be doing business with the very small number of hospitals now displayed as having the worst scores.

Here's what I mean. In the latest CMS database update, the agency categorizes hospitals that are "better than" and "worse than" in 30-day mortality and 30-day readmissions. Only about 2% to 3% of all hospitals score at the far-reaching ends of those quality scores.

For example, on CMS's measure for 30-day mortality in patients with a heart attack, only 77 hospitals out of 4,805 listed got a "better than" national average designation, while only 19 were "worse than," which is what people who might go to those 19 hospitals, or employers who might want to contract with them, really want to know.

Thirty-day mortality rates for 423 hospitals were "not available" and 1,748 had too few cases to reliably score. That leaves 2,538 hospitals with 30-day post discharge heart attack mortality rates no better or worse than national average, appearing to be OK even though many may be not that much better than the 19 worst!

It also remains unclear whether CMS will give a star ranking for every one of the nearly 100 measures now posted on Hospital Compare. Perhaps it will group certain measure categories, say 30-day readmissions for heart failure, pneumonia, heart attack, and joint surgeries, so a hospital that averaged good scores in all of those would get five stars.

AHA: Details Matter
In a phone interview Tuesday, Nancy Foster, Vice President for Quality and Patient Safety Policy for the American Hospital Association, said she also has not heard what CMS plans to do precisely. But she has heard conversations in which CMS officials have described their intent to move to "stars or bars."

At a recent meeting of the National Quality Forum, Foster recalled, Kate Goodrich, director of CMS' Quality Measurement and Health Assessment Group, related that it "would not necessarily be a system that would be one set of stars that rated the overall hospital, the way you look at some rating systems that look at hotels." But that the agency might cluster some measures.

Foster asked her how the agency would handle measures that had very little performance variation, "because frankly, when they draw lines between a five-star and a four-star hospital whose difference in performance is miniscule, that just annoys people and I think misleads the public."

Goodrich replied that the agency had taken that under consideration, Foster says. And because that is a known issue, may not use star rankings for all the measures, just for some.

"Maybe they have a more concrete idea of what they are proposing, but it has not yet been made public to the best of my knowledge," Foster says. "It is clearly intended to provide a quicker and easier way for patients to get a general gestalt of the performance of the hospital or hospitals in which they have an interest." And that's fine, she says.

What's most important to her organization and the hospitals it represents, Foster says, is that the main pages of Hospital Compare not lose the granular, specific numbers on the public display pages, which are now on Hospital Compare. Even if CMS retains the ability to download specifics in the enormous CMS database for all quality measures, Foster still wants those numbers displayed on each hospital's Hospital Compare web pages.

"Our perspective is that the most important result of quality measurement activities that have gone on this far have been to inform and encourage hospital quality improvement efforts," Foster says. "And for those purposes, the details are important. Knowing the precise number (of how a hospital scored on a particular measure) is important."

So go ahead, CMS, and display those stars next to hospital names and measures such as readmissions or central line bloodstream infections or emergency department wait times.

Just don't take away any specific numbers showing each facility's score. Hospitals need these details in order to improve.

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