As dialysis providers await their 5-star fate, news reports point out system's flaws

The five-star rating system in health care was the brainchild of Oregon Senator Ron Wyden, D-Oregon, who said during a congressional hearing in 2007 that shopping for washing machines was easier than selecting a nursing home. Medicare officials took his cue and set up a five-star rating system in 2009, a move that was applauded by consumer groups, who hoped that more transparency would lead to greater accountability.

But the renal care industry is fighting it off, asking the Centers for Medicare & Medicaid Services to take a closer look at the methodology for judging dialysis clinics, and at the clinical measures themselves—some outside the realm of the Quality Incentive Program––that are used to evaluate how clinics fare in the rating.

Many dialysis providers have complained that even with high scores from the QIP, the five-star rating system can still deliver a one- or two-star designation––even though CMS officials have said publicly that both ratings should be similar.

CMS has indicated that the ESRD Program’s rating system will start in October, but intense lobbying in recent weeks––right up the ladder to Patrick Conway, MD, CMS’s deputy administrator for innovation and quality, may help to give the renal community a reprieve. If so, the industry’s campaigning against the system may stall the agency in moving on other health care groups as well, such as home health agencies and hospitals, in the near future.

News reports look at system

Recent articles in Modern Healthcare have looked at the health care industry’s efforts to stall the rating system from moving forward, and a recent review of the five-star rating for nursing homes in the New York Times showed some flaws.

In the article, “Medicare star ratings coming soon—unless providers can put the brakes on,” Modern Healthcare’s Sabriya Rice noted that “hospital groups and dialysis and home care providers are warning that a five-star rating system the CMS plans to apply to them as early as this fall is more likely to confuse consumers than help them meaningfully compare providers' quality and safety.”

CMS’s Conway said in a June blog post that ratings empower consumers and encourage providers to strive for higher levels of quality. But the American Hospital Association, Kidney Care Partners and the Medicare Payment Advisory Commission (MedPAC) have argued that an extended timeline and comment period is needed to address key concerns over methodology. In an Aug. 15 letter sent to CMS administrator Marilyn Tavenner, MedPAC chairman Glenn Hackbarth said the 5-star rating program conflicts with other end-stage renal disease quality improvement programs. “The differences in the methods and measures might result in a facility scoring high under one program and low under the other program,” he wrote.

New York Times looks at nursing home performance

The New York Times recently reported that many nursing homes with high star ratings also had poor customer reviews and had been penalized by state health officials for substandard care. In the article, written by Times reporter Katie Thomas, individuals who had used the rating system found that the quality of the nursing homes didn’t match the 4-5-star designation. Thomas profiled a nursing home in Carmichael, Calif. that had a Medicare five-star rating, but had also faced a $100,000 fine for causing the 2006 death of a woman who was given an overdose of a powerful blood thinner. From 2009 to 2013, California fielded 102 consumer complaints and reports of problems at the nursing home. The home has also been the subject of a dozen lawsuits over substandard care, the Times reported.

The Times story also reported that while more nursing homes are climbing up to the five-star rating, they may not be truly improving. “Nationally, the proportion of homes with above-average ratings has risen steadily. In 2009, when the program began, 37% of them received four- or five-star ratings. By 2013, nearly half did,” the Times reported. But the newspaper’s analysis showed that nursing homes with a history of poor care rate highly in the areas that rely on self-reported data. Of more than 50 nursing homes on a federal watch list for quality, nearly two-thirds hold four- or five-star ratings for their staff levels and quality statistics, the Times reported, which is self-reported. The same homes do not fare as well on the sole criterion that is based on an independent review. “More than 95 percent of the homes on the watch list received one or two stars for the health inspection, which is conducted by state workers,” the Times article said.

Nancy Foster, the AHA's vice president for quality and patient safety policy, told Modern Healthcare that incomplete or unreliable information might be misguiding to patients. “(The methodology) doesn't have to be perfect, but it has to be reasonably reliable,” Foster said. “If you're going to portray overall performance with a star system, you want to make sure your methodology gives a fair assessment.” -by Mark Neumann