Hospitals, advocates await anxiously debut of overall star ratings by Medicare

The first overall rating of hospital quality performance is expected to be released soon by the Centers for Medicare and Medicaid Services.

Depending on the advocacy group and health-care system, the expanded version of Hospital Compares will either represent a realistic assessment or a misrepresentation of hospital quality.

Medicare's chief measuring stick for hospitals - available at www.medicare.gov/hospitalcompare - already offers ratings in seven inpatient and outpatient categories: complications; imaging efficiency; payment and value of care; readmissions and deaths; survey of patients' experiences; effectiveness of care; and timeliness of care. There are 57 subcategories.

Hospitals are either rated from one to five stars, or whether they perform better, even or worse than the national average.

The rankings have proven contentious locally and nationally since being introduced in 2005, particularly since the federal Affordable Care Act requires Medicare to use quality metrics in setting payments.

The 2016 version of Hospital Compares will rank 3,647 hospitals nationwide. The criteria tend to lump the majority of hospitals in the three-star category, representing the national average.

Medicare has signaled that 51.6 percent of the hospitals, or 1,881, will receive an overall three-star ranking.

There also will be 2.4 percent, or 87 hospitals, ranked as five stars; 22.5 percent, or 821, at four stars; 19.6 percent, or 716, as two stars; and 3.9 percent, or 142, as one star.

"The overall star rating represents a performance summary designed to facilitate patient and consumer use of Hospital Compare," Medicare said.

Some groups, such as the American Hospital Association, complain that academic medical centers, such as Wake Forest Baptist Medical Center, UNC Hospitals and Duke Hospital, get lower quality scores on Hospital Compares in part because they treat the sickest of the sick, along with a significant number of low-income patients without insurance.

By comparison, they say a disproportionate number of five-star hospitals are located in affluent suburban areas or don't handle complex surgeries.

Wake Forest Baptist officials have said in response to previous Hospital Compares rankings that while the government's performance review has merit, the results don't fully take into account how many very sick Medicare patients from 20 counties end up at the center, often referred from other emergency rooms.

Medicare officials say the rankings are risk-adjusted to take into account the kinds of patients a hospital serves.

Medicare officials told Kaiser Health News that its analysis showed "hospitals of all types are capable of performing well on star ratings and also have opportunities for improvement."

"The star ratings provide people a broader picture," Medicare said. "CMS used a similar approach to simplify complex quality information on other health-care quality reporting websites, such as Nursing Home Compare, Home Health Compare, Dialysis Facility Compare and Medicare Plan Finder."

Lobbying for delay

The star rankings were set to be released in April.

However, the lobbying efforts from hospital associations persuaded a bipartisan coalition of 285 members of Congress to send a letter to Medicare asking that the rankings be delayed. The N.C. members were Republicans Reps. Renee Ellmers, George Holding, Walter Jones and Patrick McHenry, and Republicans Sens. Richard Burr and Thom Tillis.

"While we strongly support public reporting of provider quality data, we urge you to ensure that this data adequately accounts for hospital patient mixes that include higher proportions of patients with multiple complex chronic health conditions and lower socioeconomic status," according to the letter.

"We also request that you provide hospitals with more details on the methodology used to determine the star ratings. We want to work together to ensure that hospitals are not penalized for treating the most vulnerable or complex patients in the star ratings system."

Medicare said in its response to the letter that it "is committed to working with hospitals and associations to provide further guidance about star ratings."

Other lobbying groups include the Association of American Medical Colleges, America's Essential Hospitals and Federation of American Hospitals.

"While the AHA supports the concept of providing an easier way for patients and communities to understand quality data, we are concerned that an overall hospital star rating oversimplifies the complexity of delivering high-quality care," the association said in a statement.

"This is especially true because the measures in the (inpatient and outpatient) quality measures were not chosen with the intention of creating a single score reflecting all aspects of quality."

Instead, the AHA wants Medicare to use star ratings just on specific clinical conditions, such as cardiac care.

The N.C. Hospital Association said its members "are investing significant resources to collect, report and use data on hundreds of quality measure to inform the public about quality and to identify opportunities for improvement."

"As currently designed, CMS's star hospital ratings program is not up to the task of providing the public with meaningful and accurate information about hospital performance. CMS should make substantial changes in the star ratings system before making it public."

Others want data

Debra Ness, president of the nonprofit National Partnership for Women & Families, a nonprofit in Washington, is urging Medicare to post the ratings.

Ness said in a blog posted Thursday that Hospital Compares offers consumers data-driven ratings for medical decisions that they typically don't have "enough information to guide them."

"Because they are unsure about where to go for trustworthy information on hospital quality, many make choices based only on a hospital's general reputation, the experiences of friends or where a physician has admitting privileges."

Ness said the star ratings "emphasize the kinds of measures that are of greatest interest to consumers: outcome measures addressing mortality, readmissions and safety, and patient experience measures.

"These measures were selected through a vigorous process that included input from diverse health care stakeholders - including consumers," Ness said. "If needed, the program can be adjusted over time.

"But now is the time to move forward and give consumers a tool that will allow them to assess which hospitals do the best job of providing the care they need."

Readmission rates

Readmission rates - patients readmitted to the hospital within 30 days of release from care - have drawn the most focus since there are financial rewards and penalties attached by Medicare to how hospitals perform. Medicare is expected to release its next readmission rate assessment in August.

Medicare assigns a death to a hospital if the patient was referred from another emergency room, but not if the patient was admitted to another hospital, then referred. That death would be attributed to the first hospital.

Many academic medical centers, including Wake Forest Baptist, point to hospital rankings issued by U.S. News & World Report. Other hospital data or rankings can be found at www.ahrq.gov, www.healthgrades.com, www.drscore.com, www.leapfroggroup.org, and at other academic or commercial websites.

U.S. News' methodology shifts some of the readmission responsibilities onto the initial hospital that treated the patient rather than the hospital that did the complex surgery.

U.S. News' ranking of best hospitals typically is dominated by academic medical centers. The magazine acknowledges that being a teaching hospital and/or having a medical school affiliation are two of the four ways a hospital is considered for ranking.

Complicating the comparison of the Medicare and U.S. News rankings is that the magazine has an advertising component with its report. It includes touting marketing opportunities for hospitals with the rankings, including buying the right to use the Best Hospital logo in advertising and to be listed among the magazine's featured hospitals.

Medicare data tend to be considered the standard measuring stick in most categories, said David Meyer, a senior partner for Keystone Planning Group LLC of Durham.

"Hospitals are sensitive to how the quality of their services is portrayed in these surveys," Meyer said.

"There is increasing pressure among employers, payers and the public for greater accountability of hospitals, foremost for them to justify the value of the expenditure and show improving quality."

rcraver@wsjournal.com (336) 727-7376 @rcraverWSJ