Ratings system may penalize hospitals serving vulnerable communities

Hospital ratings are intended to help patients decide where to get medical care and encourage hospitals to improve the quality of their services. They also can influence how insurance companies negotiate contracts for reimbursing hospitals.

But a University of Chicago Medicine analysis of the Centers for Medicare and Medicaid Services (CMS) Hospital Compare rating system shows that hospitals serving vulnerable communities may be judged on social factors outside of their control.

The CMS Hospital Compare program uses a variety of quality metrics and survey data to assign every Medicare-certified hospital in the U.S an overall rating of one-to-five stars. Since the inception of star ratings in 2016, however, hospital leaders and industry groups have criticized the program's methodology.

One criticism is that the CMS rating system does not account for social risk factors (SRFs) such as income, marital status, race, languages spoken, education and employment in the community that the hospital serves. However, these SRFs may make it more challenging for hospitals to improve certain quality outcomes.

UChicago Medicine researchers examined associations between neighborhood SRFs and seven CMS quality scores—effectiveness of care, efficiency of care, hospital readmission, mortality, patient experience, safety of care and timelessness of care—for 3,608 hospitals nationwide. The results showed that hospitals caring for patients in neighborhoods with higher social risks garnered lower quality scores, but largely in areas that hospitals may have little control over.

The impact of neighborhood SRFs was most evident in scores for timeliness of care, hospital readmissions, and patient experience. Timeliness of care, which mostly measures emergency department wait times, is heavily connected to regional access to emergency services.

Scores in safety, efficiency and effectiveness of care—measures that occur within the hospital walls—were minimally affected by SRFs.

"Our study suggests that a hospital's quality rating may be tied to its geographic location—its place," said Elizabeth Tung, MD, MS, senior author of the paper published in the journal Medical Care. "Living in a disadvantaged community can influence health directly through social factors like substandard housing conditions, inadequate access to food or transportation, and high levels of stress due to safety concerns. These factors work against well-being, so patients from these neighborhoods have more barriers to health to begin with."

John Fahrenbach, Ph.D., data scientist at UChicago Medicine and lead author on the paper, acknowledges that it is a challenge for CMS and other organizations that rate hospitals to come up with good quality metrics, but calls for more fairness and equity in their approach.

"What we are trying to say is, pay attention to—and risk adjust for—the social determinants in the communities that we serve," he said. "Don't penalize hospitals that are taking care of less-resourced patients."