Several weeks back, CMS caused quite a stir when its controversial star ratings for hospitals were released to the public.
Most pharmacists today are relatively familiar with the 5-Star Quality Rating System of the Centers for Medicare and Medicaid Services (CMS), or at least they’ve heard about it. As you probably know, the program was devised, at least in part, to be a mechanism through which consumers could compare Medicare Prescription Drug Plans (Part D).
Insurance coverage for prescriptions or medical services is a complicated system. For most consumers (and, if we’re being honest, many health care providers), it’s nearly impossible to make a well-informed decision based solely upon a plan’s explanation of benefits. Rather than asking senior citizens to suddenly become experts in insurance coverage, the star ratings system created a simple visual que, with 5 stars being the best plan and 2 stars being clearly inferior. A derivative version has even found its way into community pharmacies, with various organizations rating pharmacies on their performance on key adherence metrics that are so heavily rated for Part D plans.
Several weeks back, CMS caused quite a stir when its controversial star ratings for hospitals were released to the public. Many of the nation’s top health systems scored quite poorly compared with some of their less reputed counterparts. When the reports first came in, many wrote them off as the ratings system not adequately reflecting the severity of illness in the patient populations seen by more well-renown institutions.
Although I possess a working knowledge of Part D Star Ratings and how they impact outpatient pharmacies, I’ve had little time to research the finer points of Hospital Star Ratings. As a result, these reports afforded me an opportunity I don’t frequently have: viewing the health care system as a consumer.
According to CMS.gov, this program is “a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients. This information can help consumers make informed decisions about health care.”
Just as many of the Part D Star Ratings are rooted in the Pharmacy Quality Alliance, the Hospital Star Ratings grew out of the efforts of the Hospital Quality Alliance established in 2002. The program looks to inform consumers on how hospitals perform on metrics CMS has identified as being integral to quality patient care. Much like the Part D Star Ratings, they seem to be part of the larger goal of introducing more free-market concepts into a health system that continues to defy the economic principles idealized by the United States’ unique approach to financing health care.
Consumers are most likely to interface with the information gathered by the Hospital Star Ratings through the Hospital Compare website, which allows them to see how hospitals in a given area stack up by entering the city and state or zip code they wish to examine. If you wish to see how a specific hospital scored, you can enter its name after providing the corresponding geographic reference point.
When I entered my zip code, the website defaulted to searching for all hospitals within a 50-mile radius, though the search could be further refined to set increments that range from 1 mile to 200 miles from the reference point. The search results are then displayed as sorted by distance from the reference point. This is just the default and can be changed to sort based on hospital name, overall rating, and availability of emergency services. The search results also display “hospital type,” which classifies institutions into broad categories like “acute care hospitals,” “critical access hospitals,” “Veterans Affairs hospitals,” and “children’s hospitals.” There are a few more sort-and-search features available, but that’s generally the basics.
Staying in my consumer mindset, my easiest choice was to sort by “overall rating” or “distance” and pick my hospital based on which of those 2 elements was more valuable to me. However, the system was designed to compare up to 3 hospitals directly to provide a more in-depth look at each facility. In my area, I was able to find acute care hospitals with ratings of 2, 3, 4, and 5 stars within 50 miles, so those were the facilities I elected to compare. (I had to run a second search to compare all 4 hospitals.)
How Are Hospitals Compared?
After you’ve selected up to 3 hospitals you wish to examine in more detail, clicking the “Compare Now” button brings you to a screen that breaks down the metrics that went into the formulation of the hospital’s overall rating.
The first results screen is divided into:
The “general information” section is probably the most intuitive of all available datasets. Clicking this drop-down menu displays a set of metrics with yes/no comparators like “Provides emergency services” and “Able to receive lab results electronically.”
What caught my attention wasn’t the answers to the various tabbed submenus displayed, but the ability to click a link under the hospital’s star rating to “View rating details.” Clicking it brought me to more comparison statements better designed to illustrate how a hospital compares with not only the others selected, but the entirety of those analyzed nationwide.
The table displayed on this screen goes back to the core benchmarks seemingly assessed by the program in the comparison screen. In this table, readmissions and mortality are separate measurements. The hospitals selected are rated as “above,” “below,” or “the same as” the national average. If insufficient data has been submitted, the system displays the results for that particular institution as “not available.” Since I was testing the system out of curiosity, I was particularly interested in how great the differences for each of these metrics were between the 4 hospitals I examined.
Unsurprisingly, the hospital rated with 5 stars had all of its metrics at or above the national average. In this case, the metrics for safety of care, readmission, and patient experience were above the national average. The 4-star hospital was the same as the national average across the board, which was interesting because the 3-star hospital had above-average ratings in patient experience and timeliness of care, though data on the safety of care wasn’t available for it. The 2-star hospital was below-average for safety of care and mortality, though it happened to have above-average ratings on the readmission metric.
Going back to the previous table, the consumer can examine more information factored into the tabulation of these scores, but for the most part, it’s based on the percentage of positive responses to the assessment points for each category. For example, under patient satisfaction, the table displayed the data points for the percentage of affirmative responses to statements such as “Patients who reported that their nurses (or doctors) ‘Always’ communicated well,” “Patients who reported that their pain was ‘Always’ well controlled,” and “Patients who reported that the area around their room was ‘Always’ quiet at night.”
(Anecdotally, I found the pain control metric strangely out of date given recent considerations related to pain management and the use of subjective perceptions for prescribing opioids.)
I can’t speak to the weight any given measurement presented in the table based on the information provided. That said, anyone evaluating the effectiveness of this system must ask: “Are these truly the factors that matter most in patient care?” and “Is it best for patients to make decisions regarding who will provide them care to use the metrics displayed on this website?”
I must stress that my methodology was far from scientific. The results I found aren’t from a random sample, nor can I claim they’re representative of what the application as a whole offers consumers. However, those of us fully immersed in the health care system may quickly forget that scientific methodology and statistical significance have little to do with how most consumers perceive the tools we give them. Patients have simple goals: staying healthy, and getting better when they’re sick.
Although the significance of what they measurements used in Hospital Compare represent to the public remain to be seen, policymakers and health care providers alike should pay attention to the ramifications this program could have on our health system. It certainly has well-placed intentions, but we should be mindful of the consequences of its implementation. We don’t know how Hospital Star Ratings will be used when patients are making decisions related to their health care, but we need to ensure the results generated are truly steering them in the right direction.