Mayo Clinic got 'five stars'—but its CEO still doesn't like how CMS rates hospitals

Researchers say ratings need to account for socioeconomic status

CMS' five-star rating system for overall hospital quality—and similar systems that purport to measure health care quality—are too reductionist and need to be changed, Mayo Clinic CEO John Noseworthy argues in a Modern Healthcare op-ed.

You might think, given that CMS awarded Mayo Clinic five stars, that Noseworthy would praise the ratings system. But Noseworthy argues that "many measurement programs currently in use ... do not differentiate complexity of patient conditions nor account for their settings of care, which results in inaccurate reports on value."

One major concern Noseworthy has is incorrect patient attribution, such as when patients are classified as being treated by primary care doctors when they are actually being treated by specialists for complex conditions, such as cancer.

This happens "simply because (the patient) first came into the hospital through one door instead of another," and the error "cascades throughout the entire measurement process," Noseworthy warns. "It creates major gaps in quality and efficiency data, which ultimately renders the corresponding analyses highly suspect, if not useless."

Noseworthy also says that many systems of evaluation don't adequately account "for the patient journey." He notes, for instance, that many patients treated by Mayo Clinic are the sickest of the sick who have been referred by other providers. "Despite their histories, these same patients are often erroneously labeled as 'primary care' under some current measurement programs," Noseworthy writes.

Noseworthy says Mayo Clinic is working to come up with new metrics of health care quality, which may include "measuring cost of care over time, the speed to correct diagnosis, and the value of avoiding some expensive treatments when other oftentimes safer and less expensive treatment options are advisable."

The industry must "work together to discover better ways to evaluate and measure what we are doing to make patient-driven care better today and in the future," he concludes.

Other measurement critiques

A recent NEJM Catalyst blog post by Herb Kuhn, CEO of the Missouri Hospital Association (MHA), Mat Reidhead, MHA's VP for research and analytics, and Janis Orlowski, chief health care officer at the Association of American Medical Colleges, also critiques the CMS five-star rating system.

Kuhn, Reidhead, and Orlowski say the system's critical flaw is that it fails to account for the significant role of socioeconomic status in influencing health care outcomes. "Affluent areas are more likely to feature gourmet eateries," they write. "They're also more likely to have hospitals that get four or five stars."  

Quips aside, when Kuhn, Reidhead, and Orlowski calculated the correlation between socioeconomic characteristics of hospitals' home zip codes and the number of stars they received, they found that "the socioeconomic health of the hospital's community grows exclusively with the number of stars awarded."

Thus, "the ingredients of the star ratings depend heavily on inputs that fail to account for the upstream social determinants of health," they write. Kuhn, Reidhead, and Orlowski argue that CMS should begin accounting for socioeconomic factors when creating the ratings.

"If CMS' goal is to provide an accurate and digestible representation of overall hospital quality and value, it needs to rethink its star rating system," they conclude (Noseworthy, Modern Healthcare, 10/22; Kuhn/Reidhead, MHA article, 10/21; Reidhead et al., NEJM Catalyst, 10/24).

Navigating the maze of ambulatory clinical quality reporting

 Navigating the maze of ambulatory clinical quality reporting

CMS has implemented multiple quality reporting programs to assess the quality of care provided in the ambulatory setting. While these programs vary in their specific requirements, their shared characteristic is the tie to financial incentives or penalties, and clinical quality measure reporting requirements.

Clinical, meaningful use, quality, and IT leaders of a medical group or a physician practice need to collaborate to make critical decisions on how to balance short-term workload and resource increases with long term benefits.

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