Essential hospitals are committed to transparency and accuracy in quality measurement. However, a single rating for a hospital oversimplifies what is an inherently complex and personal decision — the choice of where to seek care.

When consumers make purchasing decisions, they shop for items online, read reviews, look at customer ratings, and ultimately choose based on a set of factors as varied as the products placed in their carts. Unfortunately, we know patients often aren’t as savvy when they make health care decisions. But some consumers are becoming more engaged in health care decision making when choosing a provider, hospital, or treatment plan. Information that is easy to understand, meaningful to patients, and an accurate representation of a hospital’s quality is of utmost importance, because these decisions could affect a person’s health and well-being.

A Single Rating

The Centers for Medicare & Medicaid Services (CMS) in 2017 launched the overall hospital quality star rating system to allow patients, family members, and caregivers to compare hospitals based on care quality. Ratings are publicly reported via CMS’ Hospital Compare website, with hospitals earning anywhere from one to five stars, five being the top score.

CMS aimed to synthesize available hospital quality information into a single rating that is easy to understand and useful for patients and consumers. In reality, a rating that combines multiple care dimensions into a single score might not represent aspects of care that are truly important to each consumer. A patient considering knee replacement surgery might look at a hospital’s complication rate for that procedure, but this information would not be as useful to a patient deciding where to give birth.

Adding to the complexity, Hospital Compare is just one of many hospital ratings systems. Other organizations, such as Leapfrog and U.S. News and World Report, have systems of their own. Hospitals’ scores can vary widely among rating systems, creating sometimes disparate and contradictory scores. Some organizations have gone so far as to “rate the raters” to evaluate public hospital quality rating programs on an A to F scale.

Association Voices Concern

The complex star ratings methodology has raised concerns about both consumer understanding of the ratings and lack of predictability for hospitals that use the ratings to guide quality improvement efforts.

America’s Essential Hospitals supports sharing meaningful hospital quality information with patients. However, we recognize that providing meaningful and fair data can be a challenge. We have observed that larger hospitals, teaching hospitals, and hospitals serving a high proportion of low-income patients receive lower star ratings despite providing quality care, often to the most vulnerable patients.

In response to stakeholder feedback, CMS has made minor enhancements to the methodology over the years. However, flaws remain that jeopardize the reliability and fairness of the ratings and ultimately do not serve the intended audience: the patient.

In February 2019, CMS updated the star ratings, which were last updated in December 2017. The release came after America’s Essential Hospitals and other hospital groups urged CMS to delay the February release due to ongoing concerns with the methodology.

With the February update, CMS also sought public comment on program changes. While America’s Essential Hospitals supports the agency’s willingness to propose changes to the program, the decision to continue to release ratings based on a flawed methodology is unfortunate, as voiced by association President and CEO Bruce Siegel.

Hospitals vary widely in the scope of services they offer and the acuity of their patients. Yet, the calculation of a single star rating for all hospitals treats them as if their overall performance is directly comparable. These ratings disadvantage hospitals that care for vulnerable patients and underserved communities. Star ratings threaten to confuse, rather than inform, consumers as they make important health care decisions. In comments to CMS, the association has encouraged the agency to examine ways to account for differences among hospitals to ensure a level playing field and accurate reflection of care quality, including peer grouping.

Will the Stars Ever Align?

A range of stakeholders continue to call for fairness and accuracy in quality reporting and the star ratings. Even more, these stakeholders want to know if and how patients are using these ratings. An expert panel, including America’s Essential Hospitals staff, convened at an August summit hosted by the National Quality Forum to share ideas to strengthen the star ratings system. The panel represented an array of perspectives: patients, consumers, employers and purchasers, health care providers, statisticians, and health plans. Among the panel’s recommendations to CMS was a call to present the underlying data in a way that meets consumer priorities and instills confidence in the ratings.

CMS also continues to engage stakeholders to gain insights about program challenges. In September, association staff attended CMS’ all-day listening session to seek further feedback on the star ratings, including methodology, usability, and potential future directions.

In what we hope will be a positive development, CMS plans to update the methodology for early 2021 based on feedback from workgroups and a technical expert panel that examined potential program changes this fall. Future changes to the star ratings will be made public through the 2020 rulemaking process.

America’s Essential Hospitals will continue to engage CMS to ensure patients and their families can make care decisions based on accurate and meaningful information.