Safety-net hospitals worry that star ratings continue to ignore socio-economic factors
SAFETY-NET HOSPITALS say the CMS continues to overlook how patients’ socio-economic factors can negatively influence how they perform in the star ratings program.
America’s Essential Hospitals was concerned to see that in the preview report of the upcoming February release of the star ratings on Hospital Compare, the CMS didn’t risk-adjust hospitals by proportion of dual-eligible stays as it currently does in the Hospital Readmissions Reduction Program.
“To not have any risk adjustment for these measures, it’s not an accurate description of the quality of care being provided at our hospitals,” said Maryellen Guinan, a senior policy analyst with America’s Essential Hospitals, which represents the nation’s roughly 300 safety-net providers. “We take particular issue with the fact that the overall star ratings don’t adjust for factors that we consider outside of the control of our members.”
The lack of risk adjustment in the star ratings can cause some hospitals to do worse, an analysis by consulting firm Sullivan-Cotter and Modern Healthcare found. Hospitals in peer groups four and five of the Hospital Readmissions Reduction Program—or those with the largest percentage of dual-eligible stays—fared worse on average than other hospitals in the readmissions category of the star ratings, according to the analysis. The readmissions category can influence a hospital’s overall star rating because it’s one of the four most heavily weighted groups considered in the star rating, accounting for 22% of a hospital’s total score.
Guinan said the nation’s safety-net hospitals treat a high percentage of dual-eligible patients and were in group five of the readmissions program. Taking into account the differences in dual-eligibility stays among hospitals is “a good first step in terms of making at least an apples to apples comparison” between hospitals, she said.
Dual-eligibles are the roughly 9 million people who are covered by both Medicare and Medicaid. Dual-eligibles are considered a proxy for patients with high-risk social factors because they are more likely to report poor health status, low-income and less education compared with patients in fee-for-service Medicare. Dual-eligibles also account for a significant percentage of Medicare spending. Although they were 18% of the
Experts said the decision by the CMS to not include the same risk adjustment from the readmissions program in the star ratings is not only unfair to safetynet hospitals but confusing to providers who use both programs for performance-improvement work.
Medicare population in 2013, they represented 32% of spending, according to the Medicare Payment Advisory Commission.
Guinan said she hopes the CMS “re-evaluates its methodology given strong evidence of a link between outcomes and social determinants.”
According to Sullivan-Cotter’s analysis, hospitals with the highest percentage of dual-eligible stays for fiscal 2019 in the readmissions program—those in peer group five—on average did worse on all nine measures the CMS uses to determine performance in the readmissions category. For hospitals in peer group four, they did worse than the national average on five of the measures. Of the nine measures, the hospitalwide all-cause unplanned 30-day readmission rate measure is by far the most influential in the readmissions category.
In the most recent methodology update, the all-cause readmissions measure was assigned a loading coefficient of 0.99, meaning it’s the most important metric in that domain that drives the total score. According to the analysis, hospitals in peer group five had an average hospitalwide all-cause unplanned 30day readmission rate of 15.71%, which is higher than the 15.3% national average for that measure in a preview of the Feb--
ruary release of the CMS star ratings.
Furthermore, SullivanCotter found that in December 2017 data—the most recent publicly available data for individual hospitals’ star ratings on Hospital Compare—hospitals in peer group five in the readmissions program had an average star rating of 2.51. That’s lower than the 3.63-star rating hospitals in peer group one.
In response, a CMS spokesperson said the methodology used in the Hospital Readmissions Reduction Program is required by the 21st Century Cures Act and “only applies to payment adjustment. This methodology is not a measure-level risk adjustment and is therefore not part of the overall hospital quality star ratings.”
The CMS will come out with new star ratings on Hospital Compare in February after a 14-month delay. The agency is supposed to update the ratings every December and July but hasn’t done so since December 2017 because of criticism that the methodology is flawed. The agency faced backlash this year when some hospitals saw a big change in their star ratings because the model evaluated the safety measures differently than in the past.
Experts said the decision by the CMS to not include the same risk adjustment from the readmissions program in the star ratings is not only unfair to safety-net hospitals but confusing to providers who use both programs for performance-improvement work. The ratings are intended to guide consumers’ healthcare decisions, but they can also provide guidance to hospitals looking to improve.
“Aligning the CMS’ programs would help to standardize peer groups and eliminate the noise in the data so organizations can create programs that improve the overall quality of care,” said Dr. Mark Rumans, chief medical officer of SullivanCotter, who wasn’t involved in the analysis.
“I think continually changing things in material ways and having things that are often at odds with one another, that is not a good way of engaging in meaning- ful measurement,” said Rita Numerof, a St. Louis-based healthcare consultant.
The decision to omit socio-economic risk stratification in the star ratings is even more perplexing as the CMS embraces the connection between social determinants of health and hospital performance, said Dr. Karen Joynt Maddox, assistant professor of medicine at Washington University School of Medicine. In November, HHS Secretary Alex Azar even talked about having Medicaid help subsidize housing, given that homelessness and substandard housing are among the biggest social ills facing many of the country’s poorest patients.
“I think there has been a real shift over the last couple of years that socio-economics matter,” Maddox said. “Continuing to say they don’t make a difference just doesn’t make sense. The star ratings are fundamentally comparing hospitals to each other, that is the whole point; so if you want to fairly compare hospitals to each other, you have to give consumers accurate information.” ●