Safety-net hospi­tals worry that star rat­ings con­tinue to ig­nore so­cio-eco­nomic fac­tors

Modern Healthcare - - News - By Maria Castel­lucci

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.” ●

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