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Policy & Regulation News

AHA: Hospital Quality Star Rating System Needs Improvement

By Sara Heath

In an effort to measure hospital and patient care quality, the Centers for Medicare & Medicaid Services (CMS) has introduced the Hospital Quality Star Rating System. However, according to a recent letter from the American Hospital Association to CMS, the system likely still has a few kinks needing to be worked out.

In the letter, AHA Acting Senior Executive for Policy Ashley Thompson claims states that although CMS’s star system is an excellent start to a comprehensive rating system, more work must be done to make the process by which the ratings are determined more credible and relevant to improving the patient experience. AHA lists several areas in which these improvements can occur.

First, Thompson addresses the criteria and categories upon which star ratings are based. She states that it is important that CMS chooses criteria that is relevant to patient experience and truly measures the quality of care provided in a certain facility. However, Thompson says much of the criteria is too narrow and does not apply to a majority of hospital patients, and that they do not directly aid patients in selecting a hospital to receive care.

Thompson suggests CMS utilize measures that would lend themselves better to hospital-to-hospital comparison. This means foregoing the use of readmission and mortality measures.

“Thus, we believe it is not possible to accurately assign star ratings to hospitals based on these non-comparable performance measures. The measures are simply not constructed in a way to permit this kind of hospital-to-hospital comparison,” Thompson writes.

Thompson also suggests CMS use simpler and more streamlined approaches for analyzing the collected data, rather than their pre-existing latent variable model. This is because a latent variable model would produce different quality results than the data stored on Hospital Compare, and this could potentially cause so much confusion that the CMS star rating could eventually be rendered useless.

“Hospitals can legitimately say that the number is not consistent with how they scored on any of the measures, nor is it an average of those scores. Further, they will have no idea what to do to improve their performance on this latent variable,” Thompson wrote. “More importantly, it may stifle improvement efforts since there will not be a clear path toward improving the score.”

The weighting of different measurement criteria is also of concern for AHA. According to Thompson, CMS has weighted four of the criteria as 22 percent each, and the remaining three as four percent each. Although it is clear that patient experience and outcomes are weighted more heavily than process measures and imaging efficiency, AHA maintains that there is no clear justification for the weighting of these measures. Thus, Thompson says, AHA suggests that CMS reconsider their weighting process and provide more clear and well thought out justifications for how much each measure is weighted.

In addition to reconsidering the weight of each quality measure, AHA suggests CMS reconsider how many quality measures each hospital must submit in order to receive a star rating. Currently, hospitals must submit three measurements to three of the categories, and that one of those categories must be an outcome group. Provided these guidelines, it would be possible for a hospital to submit a mere 30 percent of quality measures in order to receive a star rating. AHA states that quality measurements should be more stable in order to provide a clearer picture of a hospital’s quality of care.

“We believe the question of how many measures need to be in each category should be answered empirically rather than by guesswork or voting. The answer should be determined by how many measures are needed to provide a relatively stable estimate of what the hospital’s score would have been if all factors had been present, and the answer may vary by category,” Thompson wrote.

Thompson concluded by reiterating the support AHA has for CMS’s development of a comprehensive rating system for hospital quality. However, she also addresses the changes AHA believes need to be made in order to improve the star rating system and make it useful for patients.

“We urge CMS to consider moving forward with the goal of a creating a comprehensive assessment of hospital care within the next few years rather than all at once,” she wrote. “This will provide an opportunity to strategically add measures that can provide important insights into overall performance as well as take advantage of conditions for which we currently have enough information to provide an accurate assessment.”


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