In the Search for Measures that Matter, Star Ratings Miss the Mark

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From restaurant and movie reviews to websites that rate professors and real estate agents, it sometimes seems as if every aspect of our lives is facilitated by reviews and ratings.  Ratings can be a useful shortcut when deciding where to go to dinner or what movie to see, but the complex nature of health care makes developing a reliable ratings scale for hospitals a fraught proposition.  The AAMC strongly supports transparency of data and meaningful information for patients searching for their best options for care.  Unfortunately, the AAMC and our constituents are deeply concerned that, due to the flawed methodology underpinning the recently published Centers for Medicare and Medicaid Services (CMS) “Overall Hospital Quality Star Ratings,” this new system could have very serious consequences for patients, possibly steering them away from the best hospitals for their condition. 

The Star Ratings paint a confusing picture of U.S. hospital care.  While the nation’s leading teaching hospitals provide the most advanced health care in the world, only one major teaching hospital received five stars and nearly 90 percent rated three stars or below.  How could this be?  Because there is a wide array of both complex and common procedures performed at major teaching hospitals, these institutions reported more measures to CMS—often greater than 60 factors at major teaching hospitals, compared with as few as nine at other hospitals.  According to a recent AAMC analysis, the lower the number of measures reported, the more likely the institution was to receive a high rating.  Hospitals that offered the most data fared worse across the board, suggesting that the methodology behind the Star Ratings favors hospitals treating fewer conditions and offering less complex care.  

The Star Ratings also fail to account for differences in patient populations and complexity of conditions that different types of hospitals treat.  Academic medical centers provide a disproportionate amount of care to the uninsured and underinsured in our communities.  These patients are among the most vulnerable in our country and are more likely to have poorer health outcomes due to systemic inequities related to factors such as race, economic status, and level of education.  They also tend to live in communities where transportation to health care facilities, pharmacies, and other community health resources is limited.  In this population, a hospital readmission may very well be caused by these social factors rather than any failure in medical care.  By including factors such as rate of readmission in the ratings methodology, the Star Ratings give substantially lower marks to the hospitals that care for the poorest and most vulnerable in our communities.  As a result of these methodological problems, many urban hospitals that provide excellent patient care and pioneer groundbreaking therapies received fewer stars than hospitals in affluent suburbs that treat fewer complex patients.  According to Modern Healthcare, only seven safety-net hospitals—those that provide care for low-income, underinsured, and vulnerable populations—earned five stars, while 90 non-safety-net hospitals earned five stars.

Here are the facts:  Our nation’s major teaching hospitals set the standard for care in the United States and around the world.  Only 5 percent of U.S. hospitals are AAMC-member teaching hospitals, but they manage 25 percent of all Medicaid hospitalizations and provide 27 percent of all hospital charity care.  The majority of comprehensive cancer centers, burn unit beds, Level 1 trauma centers, and pediatric ICU beds in the United States are located at or affiliated with teaching hospitals.  The nation depends on teaching hospitals to respond in moments of crisis, address the gaps in our nation’s health care system, teach the next generation of doctors, and pioneer treatments and therapies that will lead us to a healthier future.  By using a methodology that fails to account for differences in patient populations and effectively penalizes hospitals that provide the most data, the Star Ratings produce confusing results that impair patients’ abilities to make well-informed choices about care providers.

In 2014, the AAMC convened a panel of experts on quality reporting to develop and issue a set of guiding principles to ensure consistent and meaningful performance ratings.  Guiding Principles for Public Reporting of Provider Performance emphasizes purpose, transparency, and validity in quality rating systems and provides direction in discerning confusing data.  The recommendations include specifying the target audience of the ratings, providing transparent information about methodology, and ensuring that methodology, data collection, scoring, and benchmarks accurately reflect the characteristic being measured.  The report also recommends that measures and methodologies be supported by clinical evidence, field-tested, and when appropriate, have endorsement from the National Quality Forum.  These steps are necessary to ensure that results are accurate and providers are appropriately characterized.

Unfortunately, instead of taking this approach, the Star Ratings have applied a one-size-fits-all model to a nuanced field.  The flawed methodology is unsuited to provide comprehensive ratings for a wide variety of hospitals and communities, and the ratings do not accurately reflect the full picture of hospital care in the United States.  As health care professionals at our teaching hospitals continue to provide world-class health care and lead quality improvement efforts, the AAMC and our member institutions will urge CMS to modify the Star Ratings methodology to take into account patient populations and complex care provided by teaching hospitals.  Until the ratings are revised, it is patients who will suffer the most from the lack of clarity and transparency, who may choose a hospital for its rating over a hospital that would provide the best care for their condition.