CMS star ratings lack vital socioeconomic, demographic factors, hospital groups say

Medicare's five-star scale that rates the quality of care provided at hospitals doesn't offer a complete picture because it fails to reflect the distinct socioeconomic and demographic factors of vulnerable patients, according to hospital advocacy groups.

America's Essential Hospitals and the Association of American Medical Colleges have urged the Centers for Medicare & Medicaid Services (CMS) in recent weeks to add the income-related information into its ranking calculations. The star-rating system, unveiled this spring, uses patient satisfaction data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to determine the scores.

In an Aug. 17 letter, Beth Feldpush, senior vice president of policy and advocacy for America's Essential Hospitals wrote to CMS that research shows a distinct risk that larger hospitals, teaching hospitals and hospitals that serve a high proportion of low-income patients will receive lower star ratings even though they provide quality care to the most vulnerable population. In addition, she complained that the proposed methodology oversimplifies complex and individualized choices that patients must make about their health.

She urged the agency to use reliable and valid measures endrosed by the National Quality Forum that account for these socioeconomic and demographic factors.

"Without proper risk adjustment, an essential hospital, serving a disproportionate share of lower-income patients with confounding sociodemographic factors, might be rated lower for reasons outside its control," she wrote.

Janis M. Orlowski, M.D., chief healthcare officer for the Association of American Medical Colleges, also complained in an Aug. 27 letter to CMS that its members worry that the untested star-rating system is misleading to patients and families. 

"A single composite rating that combines diverse quality measures, particularly those that lack clinical nuance, oversimplifies the complex factors that must be taken into account when assessing the value of the care quality," Orlowski wrote. "This is particularly true for the nation's teaching hospitals that typically care for sicker and more vulnerable patients in a diverse and complex environment."

The American Hospital Association has also been critical of the plan to phase in star ratings for similar reasons, arguing that the agency's failure to consider "a range of socioeconomic factors" beyond hospitals' control will unfairly penalize those organizations that treat larger numbers of disadvantaged patients.

To learn more:
- read the letter from America's Essential Hospitals (.pdf)
- read the letter from the Association of American Medical Colleges (.pdf)