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November 21, 2019

Why CMS' proposed star ratings changes might not help patients

Daily Briefing

    Members of a CMS advisory panel are worried that potential long-term changes to CMS' star ratings methodology won't actually help patients make informed decisions about where to go for care, Michael Brady reports for Modern Healthcare.

    Cheat sheets: How CMS calculates its quality star ratings

    CMS considers changes to hospital star ratings

    CMS' Hospital Compare website's Overall Hospital Quality Star Ratings rate more than 4,000 U.S. hospitals on a scale of one to five, with five stars being the highest. The overall hospital star ratings are based on 57 quality measures across seven categories:

    • Effectiveness of care;
    • Efficient use of medical imaging;
    • Mortality;
    • Patient experience;
    • Readmissions;
    • Safety of care; and
    • Timeliness of care.

    However, several studies have questioned the agency's methodology, and hospital groups have raised concerns about the ratings' accuracy.

    In response to providers' concerns, CMS in February updated the star ratings to rely less on patient experience and put more weight on prompt care and readmissions rates and announced it would release updated hospital star ratings in early 2020 based on its current methodology. The agency also said it was considering additional, long-term changes that would likely go into effect after the 2020 reporting year.

    In August, CMS announced plans to release a proposed rule in 2020 that would permanently change the methodology. The agency did not provide details on what changes it plans to propose but said it would use the feedback it collected from stakeholders to help guide the proposed rule.

    The agency also said it would create a panel of about 15 to 20 technical experts—including consumers, hospital quality leaders, measurement developers, purchasers, and statisticians—to help develop a new methodology for the star ratings. 

    The agency said it hopes to finalize the proposed rule before it issues new star ratings in 2021.

    Advisory panel concerned about changes

    But the CMS Advisory Panel on Outreach and Education during a meeting recently expressed concern that the changes that are currently being considered would not help patients choose where they should seek care.

    Namely, the panel said the changes to the methodology would not be useful to the patients who do not get to choose where they receive treatment, such as patients in rural communities with only one nearby hospital, patients who need emergency care who do not get to choose where an ambulance takes them, and patients covered by insurance plans with limited networks, such as Medicare Advantage or Medicaid, who have access only to a small number of hospitals.

    Panel questions whether hospitals could game the system

    The panel later expressed concerns that health systems would abuse the ratings system for their own benefit. For instance, since health systems report to CMS using one certification number, the rating of a high-performing hospital could make the lower-performing hospitals look better overall. Brady writes that hospitals were particularly concerned about multi-hospital health systems using their highest performing hospital to advertise their system, even when some of their other facilities don't perform at that level.

    Panel members were also concerned that CMS is considering adjusting for social risk factors for the next round of ratings. Experts said that while risk adjustment can make it easier to compare hospitals, they were concerned that CMS' measures would be so strict as to discourage hospitals from improving in other areas. For instance, if hospitals got better ratings for serving a higher number of high-risk patients, hospitals with a lot of low-income patients might be less likely to invest in preventing readmissions (Brady, Modern Healthcare, 11/14).

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