It’s time to scrap star rat­ings and in­stead mea­sure out­comes pa­tients re­ally care about

Modern Healthcare - - Comment - By Scott Wal­lace and El­iz­a­beth Teis­berg

Each fall, the CMS an­nounces the next year’s hospi­tal star-rat­ings al­go­rithms. An­a­lysts race to crit­i­cize or sup­port the changes (mostly crit­i­cize), while mar­ket­ing man­agers at one­and two-star hos­pi­tals go into over­drive to high­light the sys­tem’s un­fair­ness.

Jan­uary starts a new sea­son of games­man­ship as hos­pi­tals adapt to the new scor­ing rubric, seek­ing to pol­ish their per­for­mance in the rat­ings.

All of this ac­tiv­ity, how­ever, has lit­tle to no im­pact on the health out­comes that ac­tu­ally mat­ter to pa­tients. So let’s ac­knowl­edge that the CMS star-rat­ing sys­tem spurs ac­tiv­i­ties that raise costs with­out im­prov­ing out­comes and be­gin re­think­ing the con­cept of qual­ity mea­sure­ment in health­care.

First, we have to rec­og­nize that the con­cept of “hospi­tal qual­ity” is sense­less. Want proof? Try a thought ex­per­i­ment. What is the qual­ity of a hospi­tal with doc­u­mented ex­cel­lent out­comes for can­cer care but where ev­ery pa­tient who suf­fers a heart at­tack dies? Would you give this hospi­tal four stars be­cause you want peo­ple with can­cer to seek it out or one star be­cause of its car­diac mor­tal­ity? Or would you just split the dif­fer­ence?

Hospi­tal Com­pare es­sen­tially chooses the lat­ter op­tion, com­bin­ing dif­fer­ent mea­sures to cre­ate a com­pos­ite met­ric of hospi­tal qual­ity. But the prob­lem with that method­ol­ogy is that no one seeks “hospi­tal care.” When peo­ple are sick or in­jured, they seek care for their par­tic­u­lar set of med­i­cal cir­cum­stances. What mat­ters to each pa­tient isn’t some blended re­sult of ser­vices across a hospi­tal, but the par­tic­u­lar re­sults that care achieves for pa­tients with sim­i­lar cir­cum­stances or con­di­tions.

When con­fronting some­thing so im­por­tant and yet so murky as health­care, peo­ple nat­u­rally look for sim­ple in­di­ca­tors. Even bet­ter if those mea­sures are re­leased by an au­thor­ity. This com­bina- tion of sim­plic­ity and per­ceived cred­i­bil­ity ex­plains why the rat­ings from the na­tion’s largest health­care payer and by a na­tional news magazine are taken so se­ri­ously, re­gard­less of ac­cu­racy.

To be fair, re­cent stud­ies have shown some cor­re­la­tion be­tween the mea­sures that make up Hospi­tal Com­pare. For ex­am­ple, ev­i­dence sug­gests that hos­pi­tals with bet­ter pa­tient sat­is­fac­tion scores have lower over­all rates of in-hospi­tal com­pli­ca­tions. This and other small tes­ta­ments to the ac­cu­racy of the blended Hospi­tal Com­pare rat­ing, how­ever, are out­weighed by its flaws.

Among other prob­lems, the al­go­rithm used to ag­glom­er­ate the rat­ings’ var­i­ous com­po­nents will al­ways capri­ciously laud some providers while un­der­rat­ing oth­ers. The most re­cent changes, which place more em­pha­sis on read­mis­sion rates, clearly dis­ad­van­tage hos­pi­tals in low re­source ar­eas while ben­e­fit­ing those in af­flu­ent ZIP codes.

But the big­gest prob­lem with Hospi- tal Com­pare is that the whole premise is flawed. Pa­tients need in­for­ma­tion about out­comes for pa­tients get­ting care for spe­cific med­i­cal cir­cum­stances they face. The star-rat­ing sys­tem can’t pro­vide that. Mean­while, hos­pi­tals’ ef­forts to cap­ture more stars saps en­ergy and re­sources from ef­forts to mea­sure and re­port more mean­ing­ful mark­ers of qual­ity.

What health­care needs in­stead is a ro­bust sys­tem to mea­sure the out­comes that are most im­por­tant to pa­tients both dur­ing and after care. These out­comes fall into three cat­e­gories: ca­pa­bil­ity, com­fort and calm. Ca­pa­bil­ity is func­tional out­comes, or a per­son’s abil­ity to do things. Com­fort is the re­duc­tion in phys­i­cal and emo­tional suf­fer­ing as­so­ci­ated with ill­ness and in­jury. Calm is the ab­sence of chaos and in­con­ve­nience while re­ceiv­ing care.

Out­comes for ev­ery set of health cir­cum­stances can be mea­sured ac­cord­ing to this frame­work, and the re­sults will pro­vide mean­ing­ful in­for­ma­tion to pa­tients about where to seek the best care. Even more im­por­tantly, these mea­sures will pro­vide in­valu­able in­for­ma­tion to clin­i­cians that en­ables on­go­ing im­prove­ment in care de­liv­ery.

Value in health­care is cre­ated at the level of help­ing in­di­vid­u­als with the set of health chal­lenges they face. It’s time to scrap stars and mea­sure the out­comes that mat­ter most to pa­tients. ●

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Send drafts to As­sis­tant Man­ag­ing Ed­i­tor David May at [email protected]­

Scott Wal­lace is man­ag­ing direc­tor and El­iz­a­beth Teis­berg is ex­ec­u­tive direc­tor at the Value In­sti­tute for Health and Care, Uni­ver­sity of Texas at Austin.

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