An incoming technical advisory panel may suggest changes in the overall-quality star-rating program for the Trump administration.

Jan. 18—The numbers of best- and worst-performing hospitals declined in the third round of federal ratings of overall hospital quality.

The number of five-star hospitals in the Centers for Medicare & Medicaid Services’ (CMS’s) Overall Hospital Quality Star Rating program declined from 102 in July, when the program started, to 83 in December, according to recent data.

“The small number that achieved five stars shows all hospitals have a long way to go toward achieving higher safety and quality,” said Erica Mobley, a spokeswoman for the Leapfrog Group, which also reports hospital quality data. “We encourage them to continue setting a high bar, and when you get to the point where all hospitals are getting four or five stars, then it’s not a meaningful reading anymore because we know there is real variance in how hospitals perform.”

The latest ratings also reported declines in the two lowest levels of quality. The number of two-star hospitals fell to 694 from 723 in July, and the number of one-star hospitals declined to 112 from 133.

The number of middle-tier hospitals increased, with three-star hospitals rising to 1,794 from 1,770 and four-star hospitals increasing to 946 from 934.

Also notable was that the number of hospitals with enough data to receive an overall star rating decreased. CMS reported that 969 hospitals in December did not have sufficient data, which was up from 937 in July.

Other quality experts saw less significance in the fluctuations.

“It’s a little bit more data every time they add a quarter, so there is going to be some fluctuation and that is expected and not a big deal,” said Karl Bilimoria, MD, director of the Surgical Outcomes and Quality Improvement Center in the Feinberg School of Medicine at Northwestern University.

Akin Demehin, director of policy for the American Hospital Association, said the biggest shifts are expected in rating when CMS updates Medicare claims-based data, which happens every July.

“The shifts since the initial issuance of the star ratings have not been terribly significant,” Demehin said in an interview.

Measures Removed

Once reporting thresholds are met, a hospital’s overall rating is calculated using only those measures for which data are available—as few as nine or as many as 57 measures. The current average is about 39 measures, a CMS update noted.

Other developments in the overall star ratings included CMS changes in the formula for calculating the ratings, such as a reduction in the number of quality measures used from 64 in seven categories in October to 57 measures in the same seven categories.

CMS removed the following measures in December:

  • CAC-3, home management plan of care document given to patient/caregiver
  • STK-1, venous thromboembolism prophylaxis
  • STK-6, discharged on statin medication
  • STK-8, stroke education
  • VTE-1, venous thromboembolism prophylaxis
  • VTE-2, intensive care unit venous thromboembolism prophylaxis
  • VTE-3, venous thromboembolism patients with anticoagulation overlap therapy

“It looks like they are continuing to review the methodology and remove some measures that are they feel are not as applicable anymore, which is important and we encourage that—we do the same with our own methodology,” Mobley said in an interview.

The latest tweaks did not address the many concerns that hospital experts have found with the star-rating system, including the fact that all hospital types are measured with the same tool.

“That doesn’t work,” Bilimoria said in an interview.

He noted that large academic medical centers and large community hospitals usually submit data on all 64 measures, while specialty hospitals submit an average of about 24 measures.

“They are being compared on a dramatically different number of metrics, so it is not an apples-to-apples comparison,” Bilimoria said. “So I don’t think this is providing very useful information to patients.”

The “significant flaws” in the star ratings methodology are creating more “confusion than the clarity CMS would hope and we would like to see them go back to the drawing board on this,” Demehin said.

Another recent change was CMS’s decision to reduce star-rating updates from quarterly to semiannually in 2017—in July and December.

“That was a reasonably important administrative change in some ways that may be a little bit better and create a little more stability in the ratings,” Demehin said. “The fundamental methodology hasn’t really changed, though, and it still presents all of the problems and the challenges that we articulated when they first came out.”

Implications for the New Administration

Some expect that CMS will maintain the star-rating system under the incoming Trump administration despite continued concerns with the data. Mobley noted that the CMS quality-reporting and value-based payment programs began under the administration of President George W. Bush and have bipartisan support.

Rep. Tom Price (R-Ga.), whom President-elect Donald Trump nominated as secretary of the U.S. Department of Health and Human Services, has voiced support for cost transparency.

Cost transparency “is important, but it also is very critical that it be coupled with transparent information on quality,” Mobley said. She cited previous research that concluded consumers equate highest-priced care with highest-quality care.

“And that isn’t always true,” Mobley said.

It also remains unclear whether Congress will intervene in the program after a majority of legislators wrote a letter CMS in 2016 to urge delay of the star ratings. AHA has not yet decided whether it will pursue legislative interventions during the new Congress aimed at addressing concerns with the program, Demehin said.

Several organizations, including Leapfrog Group, report their own quality data on hospitals, but broadly accepted definitions of healthcare quality remain elusive.

“The bigger problem is that a lot of the data they are using are questioned; there are a lot of problems with those metrics, and most of them don’t have a formal audit mechanism,” Bilimoria said. “That wouldn’t really pass in any other industry to have public reporting of performance without any audit system.”

CMS has acknowledged that there is gaming of the rating system through the reporting of inaccurate data, Bilimoria said.

“We completely agree that the measures that exist currently are not perfect and need to be reviewed and examined for improvements, and that’s something that we should always do,” Mobley said. “But we also strongly believe that we shouldn’t get rid of the measures that we do have while we develop better measures.”

Bilimoria said it is a positive sign that CMS has begun to solicit nominations for a new technical advisory panel on the star ratings.

“That’s a good sign that they are looking for external experts to help inform what they are doing,” Bilimoria said. “Hopefully they will listen to the panel and incorporate their suggestions—that’s not always the case with those expert panels.”

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

Publication Date: Wednesday, January 18, 2017