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In July 2016, the Centers for Medicare and Medicaid Services (CMS) introduced a ratings system as part of their Hospital Quality initiative. The aim of the new program is to meet consumer demand for objective, comprehensible data on the performance and care quality of individual hospitals. Hospitals are required by CMS to distribute a patient satisfaction survey called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The results are then converted into an overall star rating. HCAHPS star ratings make it easier for patients to compare hospitals, as the scores account for procedure data, patient experience, efficiency, and other factors.
Despite the intention to empower patients, the star ratings system has received constant criticism since its inception. Naturally, rating hospitals is a complex process: facilities deliver care in a variety of ways depending on individual patient history, hospital finances, staff availability, and many other factors. Therefore, critics claim, it is misleading to use a single overall score to represent an entire hospital.
Top 10 5-Star Hospitals by Average Daily Census
|Hospital Name||Average Daily Census||Net Patient Revenue (M)|
|Mayo Clinic - Arizona||191.5||$1,188|
|Oklahoma Heart Hospital||79.7||$272|
|South County Hospital||49.0||$159|
|Memorial Hospital And Health Care Center||40.4||$212|
|St Joseph Mercy Chelsea||27.9||$138|
|Avera Heart Hospital||23.8||$101|
|Texas Orthopedic Hospital||23.4||$151|
|Hill Country Memorial Hospital||21.0||$76|
|Arkansas Surgical Hospital||18.4||$67|
|Texas Spine and Joint Hospital||14.8||$91|
Fig 1 Data from Definitive Healthcare
Industry experts are also concerned that the scores unfairly penalize hospitals serving poor and high-risk patient populations. Overall ratings are calculated based on performance in 64 measures tracked by CMS Hospital Compare, without regard for case mix. All 64 measures fall into one of seven categories: mortality, safety of care, readmissions, patient experience, effectiveness of care, timeliness of care, and efficient use of medical imaging.
Patients living in low-income areas are at a higher risk of developing chronic health conditions and being uninsured. This could impact care delivery, which could negatively affect readmission rates and effectiveness of care, lowering a hospital’s score. Additionally, critics say elements like mortality and readmissions—with disparate clinical significance—should not be given equal weight in the ratings system.
An additional factor that impacts hospital ratings is the available data on individual hospitals. Hospitals that received HCAHPSstar ratings could have reported on as few as 9 of the 64 quality measures, though the average hovers around 40. In order to be considered for scoring, a hospital must offer quality metrics data for at least 3 of the 7 categories. If a hospital only has data available for a handful of categories, it could score higher than a hospital that reports on all 7 categories—even if the latter hospital is serving patients with more complex medical issues and providing more advanced procedures.
For facilities like Arkansas Surgical Hospital or Texas Spine and Joint Hospital, that see under 20 patients per day, HCAHPS ratings should be relatively high. Because patient volume is low, these facilties have time and staff members to devote to comprehensive care and communication. For facilities like Memorial Hermann Southwest Hospital that see hundreds of patients per day, it can more difficult to keep scores above a three. The breadth of patients receiving care on a daily basis means that providers are more likely to be spread thin, meaning communication may not be as clear as patient's would like.
Top 10 Hospitals with Highest Average Daily Census
|Hospital Name||Average Daily Census||HCAHPS Rating|
|Memorial Hermann Southwest Hospital||782.2||3|
|Mayo Clinic Hospital - Rochester||748.2||4|
|Houston Methodist Hospital||617.6||3|
|Sarasota Memorial Hospital||361.9||3|
|St Davids Medical Center||331.9||4|
|University Of Washington Medical Center||329.8||4|
|St Lukes Boise Medical Center||322.2||4|
|Memorial Hermann Memorial City Medical Center||245.1||4|
|SSM Health St Marys Hospital - Madison||237.0||4|
Fig 1 Data from Definitive Healthcare
Hospitals with the highest daily census are also more likely to see patients who are uninsured or low-income, potentially affecting care delivery and outcomes. Smaller hospitals are also less likely to have comprehensive data on all 64 measures, as their patient population is just not large enough to report on. This can affect scoring, skewing ratings in favor of the smaller hospitals. However, larger facilities like the Mayo Clinic Hospital are more likely to receive greater funding to employ more staff members, purchase the latest technology, and install the best EHR system for their workflow. These factors contribute to higher clinical quality scores and can improve patient experience.
According to Definitive Healthcare data, of the 3,264 hospitals that received an HCAHPS star rating, only 125 hospitals achieved a 5-star rating—or less than 4 percent. Approximately 34 percent received a 4-star rating (1,122 hospitals), nearly 44 percent received a 3-star rating (1,428 hospitals), nearly 16 percent received a 2-star rating (520 hospitals), and about 2 percent received a 1-star rating (69 hospitals). An additional 287 did not meet reporting standards, and therefore did not receive a star rating.
Though the star ratings may be an imperfect system, they reflect consumer desire for industry transparency. As CMS quality reporting programs continue to gain traction, the healthcare industry becomes more comprehensible and providers will presumptively be held accountable in ways they weren’t required to be before.
Definitive Healthcare has the most up-to-date, comprehensive and integrated data on over 8,800 hospitals, 1.4 million physicians, 2,400 retail clinics, and more. Our database allows subscribers to search inpatient and outpatient procedure analytics by CPT/HCPCS, DRG, and ICD-9 codes, and create custom reports using clinical and quality metrics.
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