Earlier this year, the Centers for Medicare and Medicaid Services (CMS) added a new star rating system to its Hospital Compare website based on patients’ appraisals. CMS created the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Star Ratings “to enable consumers to more quickly and easily assess the patient experience of care information that is provided on the Hospital Compare website.” The rating is a composite of 11 facets of patient experience—such as how well doctors, nurses, and hospital staff communicate, the “cleanliness” and “quietness” of the hospital environment, and whether patients would recommend the hospital to others. Hospitals collect the reviews by randomly surveying patients after they leave the facility.
Medicare assigned star ratings to 3,553 hospitals based on the experiences of patients who were admitted between July 2013 and June 2014, according to an analysis in Kaiser Health News. Medicare awarded the top rating of five stars to 251 hospitals, about 7 percent of all the hospitals. Medicare gave out four stars to 1,205 hospitals, or 34 percent of those it evaluated; 1,414 hospitals, 40 percent, received three stars; 582 hospitals, or 16 percent, received two stars. Three percent, or 101 hospitals, received a one star rating.
A new article on Kevin MD dove deeper into these results. It found that “large, non-profit, teaching, safety-net hospitals located in the northeastern or western parts of the country were far less likely to be rated highly (i.e., receiving 5 stars) than small, for-profit, non-teaching, non-safety-net hospitals located in the South or Midwest.”
The differences between the groups were huge. According to the article’s analysis:
There were 213 small hospitals (those with fewer than 100 beds) that received a 5-star rating. Number of large hospitals with a 5-star rating? Zero. Similarly, there were 212 non-teaching hospitals that received a 5-star rating. The number of major teaching hospitals (those that are a part of the Council of Teaching Hospitals)? Just two — the branches of the Mayo Clinic located in Jacksonville and Phoenix. And safety net hospitals? Only 7 of the 800 hospitals (less than 1 percent) with the highest proportion of poor patients received a 5-star rating, while 106 of the 800 hospitals with the fewest poor patients did. That’s a 15-fold difference. Finally, another important predictor? Hospital margin — high margin hospitals were about 50 percent more likely to receive a 5-star rating than hospitals with the lowest financial margin.
These results don’t seem too surprising given that many of the patient satisfaction metrics seem likely to be affected by the amenities or comforts of a given hospital. Large teaching hospitals or safety net hospitals likely will not be as consistently quiet or likely voted to be as clean as a small for-profit hospital with fewer patients.
“America’s Essential Hospitals,” a trade group representing about 250 hospitals that fill a safety net role in their communities, recently articulated concerns its members had with the star rating system to CMS. Like the survey on Kevin MD, their letter to the agency noted: “our research shows there is the distinct risk that larger hospitals, teaching hospitals, and hospitals serving a high proportion of low-income patients will receive lower star ratings while still providing quality care, often to the most vulnerable” (emphasis added). Further, the group wrote that “the proposed methodology oversimplifies complex and individualized choices patients must make about their health.”
In addition to star ratings for patient experience, CMS has signaled that they will be introducing star ratings for other aspects of “quality,” including patient readmissions and complication rates. These metrics currently have more detailed information, which hasn’t yet been consolidated into a 1-5 star rating.
America’s Essential Hospitals offered their input into how CMS should move forward with their star rankings. CMS’s methodology “should incorporate risk adjustment for socioeconomic factors so results are accurate and reflect differences in the patients being treated across hospitals,” the letter states. “Without proper risk adjustment, an essential hospital, serving a disproportionate share of lower-income patients with confounding sociodemographic factors, might be rated lower for reasons outside its control.” For example, “[r]ace, homelessness, cultural and linguistic barriers, low literacy, and other socioeconomic factors can skew results on certain quality measures, such as those for readmissions.”
“It is well known that patients who lack reliable support systems after discharge are more likely to be readmitted to a hospital or other institutional setting,” writes America’s Essential Hospitals. “These readmissions result from factors beyond the control of providers and health systems and do not reflect the quality of care provided.”
Download the full letter to CMS here.