Over the past decade, the federal government has publicized 115 different ways to measure medical quality in hospitals, from assessing wait times in emergency rooms and noise levels outside hospital rooms to tracking blood clots in surgical patients. But the latest effort, to combine dozens of metrics into one patient-friendly quality indicator, has proven the most contentious.
The Centers for Medicare & Medicaid Services recently postponed its plan to release the new rating system, which would award one star to the worst-quality facilities and five stars to those with the best marks. The delay came after a majority of members of Congress 聽supporting the .
Hospital leaders who previewed the preliminary rating system say the formula seems skewed against institutions that treat the poorest or toughest patients, meaning those with complex illnesses. The number of stars would be based on 64 different measures, which are posted on Medicare鈥檚 . The metrics on mortality, readmission, patient experience and patient safety are the most influential, each representing 22 percent of a facility鈥檚 rating.
If you come out with a rating that says Cleveland Clinic is terrible but podunk hospital in North Carolina, they鈥檙e the bomb, there鈥檚 a disconnect.
Steven Lipstein, president of BJC HealthCare, a St. Louis-based nonprofit that runs 14 hospitals, said the ones in his organization that earned five stars were smaller, located in affluent areas and handled less complicated cases. 鈥淭hey don鈥檛 have comprehensive cancer centers, they don鈥檛 have major cardiovascular disease, they don鈥檛 have neuro-specialties,鈥� he said.
BJC鈥檚 more advanced hospitals did worse, he said. 鈥淭hat鈥檚 not surprising when you look inside the ratings and see how they鈥檙e built,鈥� he added.
Consumer advocates defend the rating system, saying that while not perfect, it correctly reflects higher rates of problems in some big institutions despite their lofty reputations. They worry that delay and congressional resistance are undermining Medicare鈥檚 attempt to help consumers select a hospital based on something more substantive.
鈥淭he star ratings hopefully will get quality into that decision-making process,鈥� said Andrew Scholnick, a lobbyist for AARP, the advocacy group for seniors.
Medicare officials initially said they hoped to release the ratings to the public in July. But in to hospitals and other interested parties last Thursday, they did not set a firm date.
Medicare already has made minor tweaks in the formula to calculate the stars, but it remains a tough grader, the presentation shows. If Medicare releases the star ratings in July, nearly half of the 3,658 hospitals being evaluated would be getting three stars, according to Medicare鈥檚 preliminary calculations. Just 100 hospitals would receive five stars, while 135 would receive a single star.
Officials indicated they were standing firm in their intention to eventually release the scores. 鈥淭he Overall Star Rating represents a performance summary designed to facilitate patient and consumer use of Hospital Compare,鈥� the presentation said. Officials plan to update the scores every three months through the end of this year and then twice thereafter.
The broader debate about the government judging hospitals has been going on since Medicare began publishing quality ratings in 2005. But it has intensified since passage of the Affordable Care Act, which instructed Medicare to use quality metrics in setting payments.
Teaching hospitals as a group have tended to fare poorly from some of these financial incentives. This year, for instance, are losing 1 percent of their Medicare payments because of high rates of infections and surgical complications.聽Facilities with more low-income patients, who often face difficulties affording medication, following complicated recovery instructions and getting to doctors regularly, typically have higher readmission rates.
Some health care researchers are also skeptical. 鈥淚f you come out with a rating that says Cleveland Clinic is terrible but podunk hospital in North Carolina, they鈥檙e the bomb, there鈥檚 a disconnect,鈥� said Ashish K. Jha, a professor at Harvard鈥檚 public health school. 鈥淚f it completely contradicts everything you鈥檝e known, you need to ask yourself, 鈥楧id I not understand the way hospital care works, or is there a problem with the metric?鈥欌��
Medicare鈥檚 move toward using star ratings is part of a greater focus on easy-to-grasp composite judgments of hospital quality. The Leapfrog Group, a nonprofit patient safety group, uses report-card letter grades to characterize hospital safety based on many of the same individual measures as Medicare. Healthgrades, a Denver-based company, judges hospital quality with one, three or five stars. Consumer Reports calculates a safety score on a 100-point scale.
Medicare hopes a star rating from the government will carry even more credibility.
鈥淧eople need this information now,鈥� Scholnick said. 鈥淭rying to wait until everyone鈥檚 100 percent happy with everything just delays it further than it needs to be.鈥�