Concerns of hospitals and legislators center on the lack of information on the methodological data for the overall star rating.


July 25—Continuing concerns about an overall hospital star rating system—expected to be publicly released this week—has led hospitals and some members of Congress to back a one-year delay.

The coming launch of the star rating system—as soon as Wednesday—followed the July 21 release of information on overall performance as sought by hospital advocates and members of Congress. But the lack of specific information on the scoring methodology used by the Centers for Medicare & Medicaid Services (CMS) led hospitals to support legislation—introduced July 25—that would require a one-year delay in the rating system.

“It’s not [about seeking] a delay because we don’t want this information to be made public, but it goes back to the fact that we have unanswered questions from CMS,” Beth Feldpush, senior vice president of policy and advocacy for America’s Essential Hospitals, said in an interview. “The legislation just puts more teeth into the point that they need to take care of answering some of these questions before the information is made public.”

The legislation, which was sponsored by Rep. Jim Renacci (R-Ohio), a member of the powerful Ways and Means Committee, would require “at least a year delay, with an independent validation of the methodology and a public comment period,” according to a spokeswoman. Members of the committee led the push for 225 House members and 60 senators to write CMS requesting a previous delay in the public release of the ratings, from April to July, as well as for the agency to detail its methodology.

The preliminary data reinforced hospitals’ concerns that the CMS methodology disproportionately penalizes academic medical centers and hospitals with large shares of low-income patients.

“We are very concerned about this information,” Janis Orlowski, MD, chief health care officer for the Association of American Medical Colleges, said about the recent preliminary data and CMS’s responses to the association’s technical questions.

Latest Results

Hospital scores improved at the extremes of the rating system during the most recent review period. Specifically, 102 hospitals (2.2 percent) received a five-star quality rating, compared with 87 hospitals under the data released to hospitals in April. Hospitals receiving only one star decreased from 142 in April to 133 in July.

The vast majority of hospitals were clustered in the middle: 934 (20.3 percent) received four stars, 1,770 (38.5 percent) received three stars, and 723 (15.7 percent) received two stars.

The data appeared to reflect hospital advocates’ concerns that teaching hospitals and those with lower-income patients would fare worse. The average star rating for teaching hospitals (2.87) was lower than that for non-teaching hospitals (3.11). Similarly, the average rating for safety-net hospitals (2.88) was lower than for other hospitals (3.09). CMS also found a lower mean star rating among disproportionate share hospital (DSH) payment-eligible entities (2.92) than among other hospitals (3.47).

CMS underscored that every type of hospital placed among those with the highest and lowest ratings.

“In other words, hospitals of all types are capable of performing well on star ratings and also have opportunities for improvement,” CMS stated in a release.

Concerns Specified

An analysis conducted for hospital advocates found that hospitals that reported on 40 percent or fewer of 64 quality measures garnered half of the five-star ratings. To hospital advocates, the finding indicates that hospitals that perform a higher volume and wider variety of procedures—such as teaching hospitals—have a harder time performing well than community hospitals that may perform too few procedures to report on many of the measures.

Reporting on fewer quality metrics allowed hospitals to get greater credit for performance on metrics that are more susceptible to relatively easy improvement, such as keeping rooms clean, according to Orlowski.

“What we’re saying is that the data methodology is flawed,” Orlowski said in an interview.

That also was the conclusion of an analysis of CMS’s approach performed by Francis Vella, chair of Economics for Georgetown University, on behalf of several hospitals.

“While it appears to give the impression of being rigorous and objective the estimation aspect is highly dependent on choice of measures and the weighting scheme is entirely subjective and highly determinant of the final outcomes,” Vella wrote.

Such shortcomings leave certain hospitals vulnerable to misperceptions by the public that they are inferior options for care. Some consumer advocates have urged releasing the data and then fixing any methodological concerns later, but the damage to hospitals’ reputations would be lasting.

“Our concern is that once the star ratings are released, the cat is out of the bag and the public’s perception of the hospital in their community is going to be based on that first star rating,” Feldpush said.

Orlowski said her organization is having ongoing “vigorous” discussions with CMS about the rating system, including urging the agency to delay the public launch of the overall rating until the methodological concerns are addressed.

“This is too important,” Orlowski said. “Hospitals are too complex; you can’t just throw it out and not have good data and then have it corrected.”

Orlowski said if CMS goes ahead and posts the information, her organization will push the agency to take the rating system back down until the information is accurate.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C. office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Monday, July 25, 2016