Susan E. Mazer, Ph.D. Blog

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Overall Hospital Star Rating System is Seriously Flawed

August 5, 2016

5-star ratingWhen I first heard that CMS planned on introducing a hospital star rating system, I thought, “We’ve done it! We’ve finally reduced healthcare to 5 stars, like a Motel-8!”

This is now a reality. CMS calls the star rating an “overall rating,” which considers 64 quality measures, many of them based on HCAHPS scores. And, as many of you know, I believe it’s dangerous to reduce the experience of being hospitalized to a 31 multiple-choice question survey like HCAHPS. The 5-star rating goes further.

Let’s take a step back and look at what the ratings will mean to patients and families.

Hospital Star Ratings Are Only a Summary

CMS states, “HCAHPS Star Ratings will provide a quick summary of each HCAHPS measure in a format that is increasingly familiar to consumers.”

Familiar is not always helpful. Familiar allows someone to skim the material without looking deeper. Without patient comments, similar to Expedia for hotels or Yelp for restaurants, the stars are pretty meaningless.

CMS also states that some of the questions are derived solely from Medicare patients, others are the full patient population.

Why would anyone willingly go to a hospital that is less than 5 stars when the cost of services will be the same? Payments are not based on the quality of the hospital, but on the acuity of the patient.

Right now, the majority of hospitals are in the 3-star category. Only 9% are 5-star and not all hospitals qualify for the 5-star rating system anyway.

The 11 domains that are covered in the star ratings do not report details. The measures being used for the 5-star rating are those directly about the patient experience of care. There are no half-stars, nor are there nuances between the stars, which is where the experience actually happens.

Who Will Read the Fine Print?

The star ratings are posted the Hospital Compare website along with HCAHPS scores. Because they are a “summary,” why would patients who are already stressed read the fine print? Wouldn’t they just go to the bottom line and skip the details?

The telltale question to ask is whether hospital staff would prefer to have their loved ones at their own hospital. Is the care they receive exemplary? This is the only reason to recommend a hospital.

Where there are enough specifics for patients or family members to get an idea of how a hospital treats patients, the stars are less clear. For each of the HCAHPS questions, you can see the rating comparison to hospitals within the state and then nationally. 

It’s Confusing

Where I live, we have two major, large hospitals. One hospital is considered more modern, more up to date technologically, and has the only Trauma 1 ED and the only NICU in the city.

The other hospital has been bought and sold a couple of times and remains somewhat in transition. The comparative scores of each of the domains of HCAHPS questions are about equal for both hospitals.

However, the more modernized hospital’s overall star rating is one and the hospital in transition’s rating is three. How can this be? I could not find out why by looking at the data.

Hospital Compare recommended that I speak to my physician for more details about the rating. This doesn’t seem right either.

Final Word

The star ratings are painfully simple, meaning that they do not beg for more detail. Yes, they are familiar to us, but they do not mean what star ratings mean for hotels and restaurants.

Unless it inspires better care, I am not convinced that reducing the HCAHPS scores and other data to a star rating is best for patients whose choices are limited to 3-star hospital or less.

Furthermore, on Expedia, the star ratings for hotels are a combination of cost and quality. How will a patient choose, then? How is a hospital to move its star rating up? Generalizations are so difficult to change.

What do you think?

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