Where do CMS star ratings go from here? 6 key thoughts

The CMS Overall Hospital Quality Star Ratings are under scrutiny, as the agency decided not to update the ratings in July as planned. The agency has not released plans for the next update.


"CMS has decided to postpone the July star ratings update to give time for additional analysis of the impact of changes to some of the measures on the star ratings and to address stakeholder concerns," the agency stated.

This decision comes as hospitals and health systems criticize the current CMS star rating system, including Chicago-based Rush University Medical Center alleging CMS has miscalculated hospital star ratings since 2016.

Here, six healthcare leaders discuss the star rating system for hospitals and insurers, and examine what the future may hold.

Scott Wallace. Managing Director of the Value Institute for Health and Care at Dell Medical School, The University of Texas at Austin: "Stars can't work because one can't measure quality at the level of a hospital.

In healthcare, quality is better health outcomes for the specific set of medical circumstances confronting the patient. A good outcome for a pregnant woman's delivery is dramatically different from a good outcome for a man with prostate cancer. The stars rating system conflates outcomes to a level that makes them meaningless. After all, what is the quality of a hospital that does outstanding obstetrics and awful cancer care?

Scrap stars, measure outcomes of care for every patient and recognize that care is a highly differentiated service, not a commodity."

Ken Perez. Vice President of Healthcare Policy for Omnicell (Mountainview, Calif.): "The CMS stars rating system takes the many and complex star measures and boils them down to an overall star rating, which evidently consumers increasingly understand and value, given the steadily rising popularity of Medicare Advantage plans — which are subject to the star rating system — and clear consumer preference for MA plans with the most stars. Thus, the star rating system has helped enable consumer choice and has spurred innovation by giving health plans specific areas to target for improvement. While explicitly focused on quality, the system assumes that over the long haul, higher quality care will ultimately result in less-costly care."

Alan Roberts. Vice President and Head of Star Ratings for Aetna (Hartford, Conn.): "Since every Medicare Advantage plan is evaluated against the same set of criteria, star ratings provide a good way of seeing how the plans available in your area compare to one another. A consumer can clearly and appropriately take that as a good objective measure of how one plan stacks up against another. The beauty of the program is that it takes the complicated healthcare delivery landscape and sets all of the health plans against the same standards, across a broad set of measures, and so ultimately it's all very transparent.

While the star ratings are helpful, it's important to keep in mind that health plans are not one-size-fits-all. If someone just went and looked at the plans available in their service area and decided solely on star ratings, they may end up with a plan that doesn't fit their needs. A high-performing five-star plan may not be the right match if it doesn't offer the right mix of doctors, can't be used if you travel out of state or doesn't offer the prescription drugs that support a beneficiary's care plan.

For 2018, Aetna's Medicare Advantage Prescription Drug plans earned an overall weighted average rating of 4 out of 5 stars, with 87 percent of Medicare members enrolled in plans rated 4 or higher."

Rita Numerof, PhD. Co-Founder and President of Numerof & Associates (St. Louis): I'm not surprised that the CMS star ratings have received push back from industry participants. If we look at this in context, I think it's another data point along a journey to achieve greater transparency in cost and quality. My guess is that this won't be the last time there will be controversy. If we are focused on an end goal of giving consumers real market power, we have to have a transparent view of provider performance. We haven't had that in healthcare historically. But when patients stay informed, providers are more likely to stay on their toes and that's a good thing.

The first time CMS tried to connect payments to outcomes in a way that was publicly reported was with the introduction of readmission penalties and penalties for hospital-acquired infections — never events. There was a lot of controversy about that from within the industry because physicians and health systems didn't have control over critical elements that led to these outcomes, and they were concerned about appropriate comparison. My bias has been that we need transparency in quality and cost and there should be transparency across the continuum. I think the CMS ratings, as flawed as they may be, have fostered needed discussions about quality outcomes. If we have these discussions in an ongoing way in the spirit of improving them, we will give patients a voice, which is a good thing.

Jim Schafer. Population Health Strategist with Hatfield Medical Group (Scottsdale, Ariz.): The framework of continuous quality improvement is imperative to transform care delivery in healthcare.

In order to transform the quality and effectiveness of the care that is provided to patients and certain populations, you need to reduce care variation and be able to measure specifically how you are doing compared to your peers.

Created in 2008 as a way to incentivize quality, the CMS star rating helps to give a true reflection of a plan's quality on the delivery of Medicare part C and part D.

One of the key challenges in the introduction of stars and even to today is the tracking and analyzing of the data. We are just finally moving into the stages of being able to accurately track data as the true reflection of care that was provided.

In the past most data was reflected in claims data. That can't be the only source. Thanks to artificial intelligence and increasing interoperability, we now see there's a lot more information and care provided to patients.

Joe Kiani. Chairman and Founder of Patient Safety Movement Foundation (Irvine, Calif.): "All rating systems have value in that they push hospitals to do better. That said, although not perfect, CMS is considered the best rating system because CMS uses measures which are evidence-based and predictive of the total quality and safety at hospitals.

With that said, we'd like to see CMS set even higher standards in regards to patient safety. For example, many hospitals are still not using structured handoff communication tools, or may not be continuously monitoring patients on opioids. In fact, a recent study came out which showed that 88 percent of nurses in the United States are using non-evidence based procedures for feeding tube placement and verification — leading to serious harm and even death. It would be great if CMS would use its surveyors to see if all of the Actionable Patient Safety Solutions the Patient Safety Movement Foundation has created have been implemented.

In fact, recently, the Patient Safety Movement Foundation has introduced a new ranking system based on the number of evidence-based Actionable Patient Safety Solutions that hospitals implement. Until CMS checks for implementation of all of the APSS, our ranking system can be used alongside CMS' to give the public an understanding of the number of evidence-based the hospitals have implemented. We know that if hospitals adopt these evidence-based processes, they'll have measurable success in reducing harm and creating a safer environment for our patients."


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