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How to Improve CMS's Star Ratings

News  |  By John Commins  
   October 09, 2017

More granular analyses of performance on specific medical conditions and procedures would make Medicare's hospital compare program's Star Ratings system more effective, says one observer.

For a second time in four months, the Centers for Medicare & Medicaid Services has delayed publishing revisions to its Star Ratings, which means the hospital comparison tool may not be available to the public until next year.

Rita Numerof, an author and veteran healthcare observer and consultant, believes CMS should use that extra time to reconsider some of the shortcomings of the Star Ratings system. She spoke with HealthLeaders Media about some of those challenges, and how CMS can improve the measures. The following is an edited transcript.

HLM: What needs to happen to make Star Ratings better?

Numerof: We need to make the information accessible and it has to be user friendly. The more there is scrutiny from experts around minutiae that delays the general public getting access to important information related to the performance of these hospitals, that is a problem. That is a delay tactic and it is not in the public interest.

When payment requires hospitals to focus on quality and outcomes they were able to get their act together and do it. Any industry would prefer having little to no oversight. We need a focus on transparency, quality, real accountability across the continuum and information that is made available to the consumer so that they can make meaningful choices about what is important to them.

HLM: We hear a lot of complaints about the weight given to patient experience.

Numerof: Patient experience is important, but it is not the same thing as the quality and safety of the care that I receive, and the ability of that institution to make sure that they do not have a surgical site infection, etc. Both are important, but to lump them together could really cloud the so-called quality of that particular institution.  

HLM: There have also been criticisms that the Star Ratings are too broad for the needs of many consumers.

Numerof: Star Ratings gives a directional view to a patient of the quality of that institution based on a number of legitimate dimensions. However, consumers need to have access to more detailed information with regard to how that institution performs, not in a generalized way, but in a specific way associated with a specific condition.

If I am going to get hip or knee replacement, I want to know how these institutions compare with regard to volumes and outcome rates and patient satisfaction for that particular condition. The overall hospital quality five-star rating program was intended to give an overall view, but that is different from giving specific insight about performance in a particular surgical procedure.

HLM: Does Star Ratings sufficiently account for patient mix?

Numerof: You hear industry insiders talking about how their patients are different, especially from academic institutions and safety net hospitals. There are calculations and risk stratification scores that are applied so that those organizations get compared with each other and we do take into account in the measures severity of patients’ conditions.

Last year hospitals were concerned that their coding was not accurate. That was why their scores were not as good because the risk stratification that should have been applied to their patient population which would have enabled them to do better in Star Ratings was not captured appropriately.

That led to some serious changes on that institutions’ part, where they had to make sure they had the right data in the records they were reporting to CMS. That is not a problem of CMS and the Star Ratings. That is a problem of coding accuracy on the part of that institution. We shouldn’t be curtailing public reporting of legitimate safety and quality issues because of the complexity of reporting to take into account risk.    

HLM: Why doesn’t CMS provide those specifics?

Numerof: The short answer is that it’s very political. There is enormous pushback from industry insiders, the American Hospital Association as an example, and various other organizations who have been very resistant to any kind of public reporting of quality or cost. This goes back decades.

HLM: You’ve called for a more forceful role for The Joint Commission. Please explain.

Numerof: The Joint Commission acts on behalf of CMS because CMS has allowed the accreditation process by this separate organization to stand for a CMS review. If you talk to The Joint Commission they say “We can’t force organizations to change. We are voluntarily engaged with them. They pay to be part of The Joint Commission review process.”

The Joint Commission and the industry can’t use its accreditation in promoting an institution on the one hand, and then if they get deficiencies, can’t say “we aren’t going to public report that. We are only going to publicly report the accreditation.” It can’t go both ways.

HLM: Do you anticipate any major changes to Star Ratings in the coming months?

Numerof: I expect some tweaks. There will be a focus on some of the statistical analyses, but you are not going to please all the people all the time with regard to this. There is discussion today about normalization of the data sets to avoid extremes in the data, to have better distributions. I would argue that in something like this you would want to highlight problems and not lop off extremes. You don’t want to get rid of them. You want to learn from them.

It’s a problem with statistics. The “average” is a statistical artifact. It doesn’t really exist. It’s something that we do to make sense of the data set. It’s like you’ve got one foot in a bucket of boiling water and the other foot on a block of ice. On average you are really comfortable.

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.


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