Scope of CMS Quality Ratings
As part of the Patient Protection and Affordable Care Act to improve transparency, accountability, and performance in healthcare services, the Quality Rating System (QRS) was developed to rate healthcare entities based on price and quality. This system plays a crucial role in guiding consumers, healthcare providers, and policymakers towards informed decision-making [1]. Centers for Medicare & Medicaid Services (CMS) calculates these quality ratings on a scale from 1 to 5 different measures [2]. Entities include qualified health insurance plans, healthcare facilities, and even individual providers.
CMS quality ratings extend to hospitals and various healthcare facilities, offering a standardized approach to evaluating their performance. These ratings consider factors such as mortality rates, readmission rates, patient safety, and the effectiveness of healthcare services. Patients can access these ratings to make informed decisions about where to seek medical treatment. Thus, hospitals are incentivized to achieve high ratings to attract patients and remain profitable [3]. Hospitals can also use these ratings to improve the quality of services they provide.
The scope of CMS quality ratings encompasses not only healthcare facilities but individual providers as well. Doctors, clinicians, groups, virtual groups, and Accountable Care Organizations are also subject to CMS ratings and performance review under the Doctors and Clinicians section of Medicare Care Compare and in the Provider Data Catalog [4]. Metrics such as patient satisfaction, adherence to clinical guidelines, and costs are assessed. These ratings help patients choose healthcare professionals who align with their preferences and healthcare needs. Further, providers and facilities are continuously incentivized to improve their performance and quality. This fosters a culture of accountability and encourages the adoption of best practices to achieve better patient outcomes and experiences [4].
Nursing homes, rehabilitation centers, and other long-term care facilities are also included in CMS quality ratings [5]. The Nursing Home Quality Initiative focuses on factors such as resident well-being, safety, and the quality of services provided for post- acute centers and for longer-term patients with chronic needs [5,6].
The scope of CMS quality ratings is vast and highlights a movement within healthcare towards standardization. The standardization of healthcare quality measurement allows patients not only to access information about health plans, but also incentivizes the healthcare industry to improve the quality of services and thus, overall patient outcomes. Further, by providing a comprehensive assessment of the performance of healthcare entities, these ratings promote transparency and accountability. As healthcare continues to evolve, quality ratings will remain a critical tool in the pursuit of delivering high-quality, patient-centered care.
References
1. Centers for Medicare and Medicaid Services Overall Hospital Quality Star Rating. 2019 Available online: https://www.medicare.gov/hospitalcompare/Data/Hospital-overall-ratings-calculation.html
2. Kurian N, Maid J, Mitra S, Rhyne L, Korvink M, Gunn LH. Predicting Hospital Overall Quality Star Ratings in the USA. Healthcare (Basel). 2021 Apr 20;9(4):486.
3. Yaraghi N., Wang W., Gao G.G., Agarwal R. How online quality ratings influence patients’ choice of medical providers: Controlled experimental survey study. J. Med. Int. Res. 2018;20
4. Centers for Medicare and Medicaid Services 2021 Quality Payment Program (QPP);2021 Available online: https://www.cms.gov/files/document/2021-qpp-performance-information-medicare-care-compare-presentation-slides.pdf-0
5. Tamara Konetzka R, Yan K, Werner RM. Two Decades of Nursing Home Compare: What Have We Learned? Medical Care Research and Review. 2021;78(4):295-310.
6. Harris Y., Clauser S. B. Achieving improvement through nursing home quality measurement. Health Care Financing Review. 2002;23(4), 5–18.