Quality and Cost Reporting

Why Hospitals Are Optimistic About Prospects for Star Ratings Overhaul

May 6, 2019 4:02 pm

March 28—Hospital advocates hope an appeal tuned to the Trump administration’s focus on reducing costly and time-consuming provider burdens will pay off in an overhaul of the hospital star-rating system.

Various hospital advocacy groups urged the administration this week to take down the rating system until it is revamped and simplified. Their comments to the Centers for Medicare & Medicaid Services (CMS) followed regulators’ solicitation of ideas on ways to improve the rating system, which has elicited extensive hospital concerns.

And hospital advocates are optimistic CMS will accept suggestions.

“Recently, CMS has really rethought their approaches to measurement in the Meaningful Measures Initiative, which resulted in a reduction of measures that we previously found burdensome across CMS programs,” said Aisha Pittman, senior director for payment and quality policy at Premier Inc. “The star rating is another prime example of something that creates unnecessary burdens.”

Another positive sign was that the overhaul ideas for which CMS sought comments by this week moved well beyond “tweaks on the existing methodology,” Pittman said in an interview.

Optimism that CMS will pull down the ratings while they undergo changes stems from the agency’s prior decision to pause the rating update during a 2017 overhaul.

Why Change Is Needed

The ratings have been little used by the general public, but Pittman acknowledged they have generated negative local press coverage for some of her organization’s member hospitals. Addressing such concerns is difficult because CMS does not identify the details of the ratings methodology.

“If you’re a consumer looking at the stars of hospitals in your area, and you notice that from one update to the next they all shift and you want to know why, and when the hospital itself can’t explain why, that leaves consumers without an understanding of what the quality of care really is,” Pittman said.

A December 2017 update to the star ratings—which followed an overhaul of the methodology— changed the rating of nearly half of U.S. hospitals. 

Other concerns with the star ratings cut across several broad areas that involve:

  • Lack of useful information for patients seeking specific services
  • Lack of reproducibility to identify how hospitals can drive improvements
  • Lack of clarity on what factors drove ratings changes following the last overhaul
  • Inability of patients to personalize ratings based on specific care needs
  • Lack of accounting for differences in clinical and social risk factors among patients and communities

“The changes in the star ratings from one update to the next can result in a significantly different score for some hospitals, but then it is really hard to drill down and understand what is contributing to it,” Pittman said.  

Changes Sought

Several hospital advocates were supportive of a CMS proposal to allow users to customize ratings.

“However, we believe more investigation is needed to better understand patient and consumer interest in and understanding of the concept to ensure that any tool meets their needs and is not overly burdensome or complex,” Janis Orlowski, MD, chief healthcare officer for the Association of American Medical Colleges (AAMC), wrote in comments to CMS.

American Hospital Association (AHA) support for the changes was based on proposals that involve:

  • Empirical criteria for measure groups
  • Peer-grouping star ratings among similar hospitals
  • Using an “explicit” scoring approach that specifies the weights of each measure in a measure group

AHA “believes a less complex ‘explicit’ approach to scoring hospital star ratings may be the most promising long-term option for improving star ratings,” according to a letter from the association.

AAMC supports a proposal to move from a semiannual to an annual update cycle until the reliability and stability of the methodology improve, and another recommendation to adopt “partial-star” overall ratings.

Allowing for ratings of 2.5 stars or 3.5 stars, for example, would reduce the drop-off among categories of hospitals and provide greater clarity to patients and consumers on a hospital’s relative performance, Orlowski wrote. The CMS home health agencies ratings and Medicare Advantage plan ratings already use half-stars.

Additional steps not suggested by CMS but needed to improve the rating, according to AHA, include:

  • Engaging an expert group on latent variable models (LVMs)—which would be replaced if a more explicit scoring system is adopted—to ensure the calculation approach is executed correctly
  • Examining how to mitigate the impact of outliers on the calculation of readmissions measures in the ratings
  • Developing an alternative approach to star ratings in which, instead of an overall rating, hospitals receive ratings on specific clinical conditions or topic areas

“Ultimately we just want them to move to something that is much clearer in its approach to calculating the star rating,” Pittman said.

Hospitals have been unable to replicate the LVM and want it replaced with more transparent measures using static weights that change infrequently, The hope would be “that hospitals themselves can anticipate what their star rating is, know where they are going to land, know how it relates to their other quality improvement efforts, and be able to determine what intervention they’re going to put in place as a result of that methodology,” Pittman said.

Changes Opposed

AHA opposed CMS’s proposal to use the “closed form” computational method for the LVM, citing an inability to compare that approach with the current methodology.

Additionally, AHA strongly opposed any approach to scoring hospitals on individual components of the patient safety indicator (PSI) composite measure, writing: “In fact, the AHA continues to urge CMS to transition PSI measures out of all of its measurement programs.”


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