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 one- and 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 combination 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 Hospital 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.