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Hospitals May Soon Be Reaching For The Stars

Jul 18, 2013

Star wars may be coming to a hospital near you.

Medicare is considering assigning stars or some other easily understood symbol to hospitals so patients can more easily compare the quality of care at various institutions. The ratings would appear on Medicare’s Hospital Compare website and be based on many of the 100 quality measures the agency already publishes.

The proposal comes as Medicare confronts a paradox: Although the number of ways to measure hospital performance is increasing, those factors are becoming harder for patients to digest. Hospital Compare publishes a wide variety of details about medical centers, including death rates, patient views about how well doctors communicated, infection rates for colon surgery and hysterectomies, emergency room efficiency and overuse of CT scans.

In its proposed rules for hospitals in the fiscal year starting Oct. 1, the Centers for Medicare & Medicaid Services asked for ideas about "how we may better display this information on the Hospital Compare Web site. One option we have considered is aggregating measures in a graphical display, such as star ratings."

Private groups such as Consumer Reports, the Leapfrog Group and US News and World Report already issue hospital guides that boil down the disparate Medicare scores -- along with their own proprietary formulas -- to come up with numeric scores, letter grades or rankings.

But even before it's formally proposed, the possibility of the government rating hospitals based on a star system is receiving less than heavenly reviews. In a letter to Medicare, the Association of American Medical Colleges said it "strongly opposes the use of a star rating system, which may make inappropriate distinctions for hospitals whose performance is not statistically different. A star rating system can also exaggerate minor performance differences on measures."

In a statement, Medicare defended the idea. "Visual cues can be an important way to help patients understand how their hospital measures up to others," it said, adding that the government is interested in hearing from people about "user-friendly, creative designs for a rating system to help patients get information so they can take an active role in their care."

Peter Slavin, president of Massachusetts General Hospital, said making medical care standards more comprehensible is a worthwhile pursuit, but a good hospital ranking system would need to be based on more sophisticated underlying data than what’s now available.

"The quality information we're now using in health care is pretty crude and needs to get a lot better," Slavin said.

Much of that data is derived from the bills hospitals submit to Medicare, which he said is "a lot like judging the quality of a restaurant from the checks they give to their customers."

Slavin questioned whether star ratings would be useful for patients seeking specific services, such as a lung transplant, which Medicare does not evaluate.

"At some point if you oversimplify things, you're not providing people with information that is all that meaningful or helpful," he said.

Robert Berenson, a health policy researcher at the Urban Institute in Washington, D.C., also wondered whether there is enough solid information about medical care quality available to make star-rating system effective.

"I recognize the appeal of making things easy for consumers by giving stars, but I don't think the data is robust enough and valid enough," Berenson said. "There are important gaps in what's measurable. What gets considered important is what we can measure, not the other way around."

But Tanya Alteras, deputy director of the advocacy group Consumer-Purchaser Disclosure Project, was more enthusiastic about a star system. "If it's tested with consumers and shown to be useful we are definitely in favor it," she said.

Medicare already uses a five-star system to rate the private Medicare Advantage health insurance plans. A quarter of U.S. seniors get their insurance from these private insurers, which Medicare helps pay for, instead of through traditional Medicare, which pays hospitals, doctors and other providers directly for medical services. Those stars carry extra gravity because Medicare gives financial bonuses to high-performing plans.

But applying such a system to hospital quality could be challenging. Private groups have come up with differing judgments on the same hospitals. For instance, hospitals given an "A" in patient safety by Leapfrog for patient safety can end up at the bottom of Consumer Reports’ rankings because of differences in their analyses.

And even Medicare's current evaluations of hospital care and services don't always lead to consistent overall conclusions. For instance, Medicare rates Beth Israel Deaconess Medical Center in Boston as above average nationally in keeping heart attack, heart failure and pneumonia patients from dying, but below average in readmissions and the frequency of collapsed lungs and accidental cuts and tears during treatments.

Beth Israel declined comment for this story.

Also, Medicare's current quality evaluations using statistical tests end up concluding most hospitals are indistinguishable from one another on major performance measures such as death rates. On Hospital Compare, 9 out of 10 hospitals' mortality rates are described as "average." That kind of narrow range doesn't lend itself to a star system, said Leapfrog executive director Leah Binder.

"If their plan is to give the same number of stars to all the hospitals, at best it will be boring," Binder said. "At worst it will be misleading."

jrau@kff.org

This article was produced by Kaiser Health News with support from The SCAN Foundation.

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