The first group of star ratings are out for Hospital Compare, the Centers for Medicare & Medicaid Services’ (CMS) hospital rating system. These ratings are related to patient satisfaction scores. What’s newsworthy is that just 251 of the more than 5,000 hospitals in the country achieved five-star ratings — and about half of those hospitals are specialty facilities like orthopedic or heart hospitals, not the general facilities that most people will use.

What does that mean? Should a hospital be concerned if it is only getting two or three stars? And does a five-star rating have meaning in a world where one hospital ranking system can give you that, but the next — Leapfrog Group or U.S. News & World Report — can have you just average or less? The ratings are meant for consumers, but should the hospitals themselves pay any attention to them?

“At a high level I would say that it is certainly meaningful to be five stars versus one star, but perhaps not five versus three,” says Donald Kennerly, MD, PhD, principal consultant for Kennerly Healthcare Solutions in Dallas. “There is a certain amount of gaming going on now by hospitals related to their coding of inpatient encounters, which is leading CMS to rethink how they evolve their rating system for use in the future,” he says.

In the interim, the first reason to care is that there will be reimbursement penalties for hospitals that are in the lowest quartile of some of the measures included on Hospital Compare, he says. “These are non-trivial amounts of money.”

He has several caveats, even given the money on the table. First, Kennerly says that some of the hospitals are bound to have sicker populations — such as academic medical centers or inner-city hospitals — and they may have worse scores based on the quality of their care.

Jim Bialick, president of the Patient Safety Movement Foundation in Lake Forest, CA, notes that often patients only fill out surveys if they have a bad experience, and often that coincides with bad outcomes.

Given those realities, it’s possible that those large hospitals with sicker patients may have skewed results that Kennerly says is due “in part to the nature of their patients, not the quality of their care.”

Another thing to think about when considering your facility’s status among the rankings — on Hospital Compare or any other list — is that patients are much more likely to use the recommendations of their physicians about hospitals than those of any reported ranking for elective care, and with emergent care, “they don’t look at the star ranking; they go to the emergency department that is close to where they are.”

The differences between hospitals, too, may be fairly small, Kennerly says. Bialick agrees, noting that understanding the methodology behind the ranking is as important as the ranking itself. “It is important to understand why a hospital gets a star in the first place: It is because that hospital has performed above a national or regionally adjusted average. But you do not get more of a star for being way better than the average. This means that if the national average is 50%, hospitals that score a 51% get the same star as a hospital that scored a 99%.” Unless you dig down and figure the exact scores through information at, Bialick says, you might not be able to see how you compare to the hospital across town.

Kennerly says that there may be very few points separating a high performer from an average performer. It’s like a teacher grading on a curve: An entire class may score between 90 and 100%, but someone is going to get a failing grade, and the students getting A’s and B’s may be just a few percentage points away from someone getting a C or D.

Then there are those hospitals that are not driven to achieve excellence, but do worry about whether they will lose money if they are close to some low-performing boundary, says Kennerly. When these differences get very small, CMS may retire the metric since it doesn’t differentiate well.

Lastly, Kennerly says many hospitals aren’t overly motivated by goals to achieve “excellence” per se, but do worry about whether their CMS-derived revenues might be reduced if they are close to the low-performing boundary.

Bialick says that the ranking systems in place right now “have a tremendous opportunity to incorporate more safety data and, in turn, motivate hospitals to make safety their top priority and empower patients to make their decisions on facts rather than opinion.”

That said, these star ratings are a “relative unit of measure,” Bialick says. “Some of the scores are based on patient satisfaction surveys, others on voluntary responses from hospitals themselves. The reality is that patients are more likely to fill out a satisfaction survey when they have had a negative experience, and if a hospital does not fill out a survey they get an automatic F. For patients, this may not offer a lot of clarity or value.”

Given that there are various models for rankings, and they all have different metrics they use, Bialick thinks the star system is important because it resonates more with people. “I see promise with the star rating system in Medicare advantage [Part C] because the methodology can be expanded or fine-tuned over time.”

For example, he would like to see questions added to the survey such as:

• Does the hospital have evidence-based prevention strategies in place for the leading causes of preventable medical errors?

• Does the hospital have an interoperable EHR system?

• Does the hospital offer telemedicine services?

Right now, stars are what consumers are going to use, so Bialick says for that reason, they matter. Transparency about quality of care is also increasingly important to patients, he notes. That means providing data in whatever form resonates with patients. “If hospitals want to make it matter to their patients and want to market their hospitals as safe, they should make their strengths and weaknesses transparent to potential and current patients.”

For more information on this topic, contact:

• Donald Kennerly, MD, PhD, Principal Consultant, Kennerly Healthcare Solutions, Dallas, TX. Email:

• Jim Bialick, President, Patient Safety Movement Foundation, Lake Forest, CA. Telephone: (949) 297-7047.