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My Favorite Slide: Why Five-Star Hospitals May Be More Closely Related to Five-Star Restaurants than Innate Quality

Blog Post · October 24, 2016

Five-Star Hospitals: CMS Star Ratings by the Socioeconomic Well-Being of U.S. Hospitals' Home ZIP Code (n = 4,336)

CMS Star Ratings by the Socioeconomic Well-Being of U.S. Hospitals’ Home ZIP Code (n = 4,336). Click To Enlarge.

Affluent areas are more likely to feature gourmet eateries. They’re also more likely to have hospitals that get four or five stars in the new Quality Rating System from the Centers for Medicare & Medicaid Services. Based on latent variable modeling of 64 quality measures, the rating system is intended to be the culinary equivalent of a reduction sauce, where multiple ingredients meld to create a rich flavor. Whether all of the nuanced dimensions of hospital quality can be reduced to a scale of one to five is subject to debate. However, any gourmand can attest that a good reduction sauce is about the right mix of ingredients and time. As it now stands, the star ratings system has neither.

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.

Using the star rating data provided by CMS, we evaluated the socioeconomic characteristics of hospitals’ home ZIP codes by the number of stars they’re awarded on the Hospital Compare website. This slide shows a portion of our findings. Evaluated by an area-level socioeconomic deprivation index that measures multiple factors such as education, poverty, unemployment, environment, and income, we found that one-star hospitals reside in ZIP codes that are nearly three rungs lower on the SES ladder than five-star hospitals. 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.

If CMS’ goal is to provide an accurate and digestible representation of overall hospital quality and value, it needs to rethink its star rating system. Before regulators try to make the reduction sauce, they need to correct the ingredients to ensure their patrons get the true flavor of quality.


This blog post originally appeared in NEJM Catalyst on October 20, 2016.

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