CMS star ratings criticized for ignoring socioeconomic factors

CMS’ star rating system is more about the affluence of patients than quality of care, argued Missouri Health Association CEO Herb Kuhn, Mat Reidhead, MA, Vice President of Research and Analytics for the Hospital Industry Data Institute, and Janis M. Orlowski, MD, Chief Health Care Officer of the Association of American Medical Colleges.

In a NEJM Catalyst commentary, Kuhn, Orlowski and Reidhead compared five-star hospitals to five-star restaurants, arguing both are more prevalent in wealthy areas. The variable modeling of 64 different quality measures broken into seven domains isn’t the “right mix of ingredients,” as they put it.

“The ingredients of the star ratings depend heavily on inputs that fail to account for the upstream social determinants of health that largely determine downstream health outcomes for patients from indigent communities, who rely on the nation’s safety-net hospitals for access to the entire continuum of care—primary to quaternary,” Reidhead et al. wrote.

Their preliminary research evaluated socioeconomic factors, like education, poverty, unemployment, environment, and income in a hospital’s home ZIP code. What they found was a correlation between between the star rating and the kind of patients it serves, with the poverty rate around one-star hospitals being nearly double around five-star facilities.

“In fact, we found that the socioeconomic health of the hospital’s community grows exclusively with the number of stars awarded, and many of the one- and two-star hospitals are among the country’s elite academic medical centers that treat the most complex patients, who face both clinical and social comorbidities,” Kuhn, Orlowski and Reidhead wrote.

In almost all the socioeconomic categories examined, there was a clear relationship between the communities and their star ratings. As rates for unemployment, people with less than a high school education and childhood poverty in a hospital’s home ZIP code fell, star ratings went up.

In some categories, there were small discrepancies. For example, median household income was higher around one-star hospitals ($47,248) than two-star hospitals ($46,982). The percentage of non-white population was higher at five-star hospitals (24.1 percent) than four-star (18.8 percent). The stark difference between one and five-star hospitals, however, remained in both categories: median household income was more than $11,000 higher around five-star hospitals and the non-white population was 22 percentage points higher around one-star hospitals.

Kuhn, Orlowski and Reidhead said they’ve submitted their comments to CMS, but haven’t received a response.

“CMS rushed the release of the star ratings through an opaque review and endorsement process at (National Quality Forum), even with a brief delay induced by Congress, during which time they addressed very few industry concerns,” they wrote in an accompanying blog post. “But the larger problem is with their ingredients. The continued decision to exclude social factors from the risk adjustment of measures underlying the star ratings is an elephant-sized fly in the soup.”