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Expert calls CMS hospital star ratings delay a major mistake

Hospital Compare initiative has become a "problem child" for CMS, but discussion over methods shouldn't be allowed to stall program repeatedly.

Beth Jones Sanborn, Managing Editor

When the Centers for Medicare and Medicaid Services once again delayed the release of updated overall hospital quality star ratings on Hospital Compare, the agency was quoted as saying they decided not to proceed with the October update "to continue its examination of potential changes to the Star Rating methodology based on public feedback" and the star ratings released last December would remain on the Hospital Compare website until the next update, CMS said.

If there is one thing CMS has gotten plenty of when it comes to the star ratings, it's feedback. And a lot of it is negative. Michael Abrams, managing partner of consulting firm Numerof and Associates, said the star ratings initiative has become a "problem child" for CMS, and it's disappointing to see the program faltering.

[Also: CMS delays October star ratings release as advocacy groups push for major methodology overhaul]

The ratings were scheduled to be updated in July 2017, one year after the program launched. And over the course of that year, numerous organizations including the American Hospital Association and America's Essential Hospitals have voiced disapproval of the current program and how it works, the overall message being that the ratings don't create accurate picture of quality on which consumers can rely.

Abrams said it's par for the course when it comes to healthcare, an industry that has never been able to tout accountability or transparency as cornerstones. "Healthcare is one of the few things that we purchase where you don't know going in what it will cost, don't get guarantees about satisfaction or what you'll get in services, but there is no such thing as refusing to pay."

[Also: Hospitals get time to preview star ratings, CMS says]

Abrams conceded there is validity to some of the criticism. There are seven factors in the star ratings approach: five of them relate to safety and quality, one captures patient experience and one captures efficiency with imaging. He said one could argue this might not be the best approach in that it is too skewed and does not strike a useful balance. Also, he pointed out that patient experience is already given substantial consideration in HCAHPS, so perhaps they don't need to be in this calculation.

"Maybe you should decide what this rating represents and then stick to it. If it's supposed to be about safety and quality then make it all about that and don't throw in one dimension on experience and one on efficiency. No one is pretending that safety and quality tell the whole story. We all know there are other dimensions that go into choosing a hospital. But let's not mix a mostly apples with a few oranges."

He also agreed that because hospitals, by virtue of number and type of patients they see, often don't wind up reporting on all metrics that can go into star rating model. Sometimes the star rating itself is compiled based on however many metrics are reported on by the hospitals, with some metrics left incomplete or blank. So the weight that would have been given to dimensions of quality and safety that are missing are added to the metrics that were reported. Abrams said this often leads to overweighting what's reported. This potentially biases that rating and encourages hospitals to only report favorable data which then winds up being the sole basis on which the rating is calculated. That needs to be addressed, Abrams said.

"Below a certain threshold it does not make sense to include facilities in the calculation when as few as nine metrics out of 57 or 64 are being reported. So you do have to draw the line somewhere and it's certainly arguable that that bar has not been raised."

However, the delays are detrimental to the program and to patient safety, Abrams stressed, and the quest for a perfect methodology shouldn't be allowed to be the enemy of forward progress.
Dragging out the process and delaying implementation gives cover to a level of cultural resistance that needs to be addressed, and transparency is desperately needed.

"Research shows unacceptable rate of harm for patients during hospitals stays; far too many are injured in preventable events. That honestly is testimony to the failure of CMS to oversee hospital safety and should lend urgency to cms's efforts to provide more transparency," Abrams said.

Twitter: @BethJSanborn
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