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In the movie, “The Hundred Foot Journey,” Helen Mirren plays the owner of a French restaurant who has sought in vain to win the Michelin Star for her cuisine. Restaurants that win a star are listed in the Michelin Red Guide, a series of annual books published by the French company Michelin (yes, the tire maker) for more than one 100 years. The acquisition or loss of a star can have dramatic effects on the success of a restaurant.
We’re not sure the five-star rating system for dialysis providers will be around for 100 years, or whether it will have the same impact as the Michelin star does for restaurants. The five-star ratings went live Jan. 15 on the Dialysis Facility Compare website, and we haven’t heard about patients walking out en mass after discovering their clinics only had two stars. Likewise, we haven’t seen clinics boasting about their five-star ratings on billboards across the country.
That’s because the message about these ratings is still somewhat murky. What does a five-star rating really mean—or a two-star rating?
Make it simpler
The Centers for Medicare & Medicaid Services developed the star rating system for dialysis providers to accompany data on the DFC website, after determining that the raw data was too complex. The star ratings are based on that data, along with a few more quality measures added into the mix.
Star ratings and “compare” websites are not unique to dialysis; CMS has similar programs for nursing homes, home health agencies and, most recently, hospitals. Physicians are the next targets.
CMS says that the star ratings are part of Medicare’s efforts to make data easier to understand and for consumers to use. But here is where the explanatory language—located on the DFC website—gets a bit unclear for dialysis patients:
“The star ratings show whether your dialysis center provides quality dialysis care —that is, care known to get the best results for most dialysis patients. The rating ranges from 1 to 5 stars. A facility with a 5-star rating has quality of care that is considered 'much above average' compared to other dialysis facilities(emphasis added by author).
And, what if you are a one-or two-star facility?
A 1- or 2- star rating does not mean that you will receive poor care from a facility. It only indicates that measured outcomes were below average compared to those for other facilities.
The DFC website urges patients to “See how your facility compares to others based on star ratings.” And, “Talk to your doctors about the star ratings when you decided to get dialysis.”
So if I am a patient, should I tell my nephrologist that for my first dialysis treatment, I want to avoid any facility with two stars? “But Medicare says you will not receive poor care at the clinic I am recommending (which may also be a clinic that my practice group has a contract with and where I send most of my patients),” the nephrologist counters. “And it is the clinic closest to your home.”
CMS added the disclaimer that low stars do not’t mean poor care after the renal community howled over the implementation of the rating system. But pacifying dialysis providers may in fact make the significance of star ratings less clear for patients. If CMS tells me to “see how your facility compares to others based on star ratings,” but then says, “A 1- or 2- star rating does not mean that you will receive poor care from a facility,” it becomes confusing: Does a low star rating mean poor care – or not?
How stars shine
Our NN&I cover story last month by Mark Stephens compared facilities with good performance scores in the Quality Incentive Program to the five-star rating. He found few similarities between the two. CMS counters that they are two separate evaluation systems and should not be compared.
I did a comparison of three dialysis clinics in my hometown of Scottsdale, Ariz. I picked a one star, three star, and a four-star clinic. All were within 20 miles of my location.
All three clinics, according to CMS, have hospital admission and hospital readmission rates “as expected.” The three-star and four-star facilities also had mortality rates as expected. The one star clinic had a mortality rate “worse than expected,” according to the profile. But it’s not clear how much: if 1.00 is “as expected,” was this clinic 1.06? How "worse" is "worse"? The data isn’t provided.
Then the star rating system looks at clinical measures: Kt/V, the percentage of patients dialyzing with a fistula, and the number of patients with hypercalcemia (calcium >10.2 mg/dl). These quality measures are similar to what facilities must meet in the QIP.
In a side-by-side comparison of these three clinics, the four-star clinic did better in several categories—but not always by much.
• The one-star clinic had 94% of its patients with a Kt/V greater than 1.2; the four-star clinic had 95% of its patients hit that quality measure.
• Both the one-star and the four-star clinic had no patients with hypercalcemia.
But the one-star clinic had more patients with catheters (57% vs. 74%) and 26% of its patients still had catheters after 90 days (v. 9% for the four-star clinic). And that one-star clinic had a higher mortality rate, although we don’t know how much. So those differences in criteria made the difference in the star ratings.
Room for improvement
A special Technical Expert Panel met in late April to take a closer look at the rating system—another concession by CMS in response to the renal community’s displeasure with the system. Word is that the two-day meeting, organized by the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) under contract with CMS, produced some constructive debate. The panel was well represented by dialysis patient groups and providers, as well as experts in biostatistics. We’ll see if it leads to any changes.
Two things to consider: the Hospital Compare rating system does not use the “bell-shaped” curve formula that forces a set number of providers into each “star” rating. And hospitals can see their rating improved every three months based on how quality scores change. Currently, dialysis facilities have to wait a year before they can see their rating improve.
Let’s make it real
CMS’ goals are well intended with the star rating system: provide consumers with good information to help guide them in choosing a provider. The DFC site is well done and charts and graphs make it easy to make comparisons. But the star rating system was maligned from the first day it was presented, and forced on the renal community with little input on its methodology.
If it is to be a quality rating system, it needs to have the respect of those who it rates. Like the Michelin Star.
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Professional dialysis recruitment
Morrinsville Lions Club members chop firewood to raise funds for a modified van for dialysis patients. Photo: SUPPLIED Dialysis patients will soon be able to take a much needed holiday after a $110,000 donation towards a modified campervan.The Morrinsville Lions Club donated $110,000 to the Regional Renal Centre for a $150,000 modified van to help those on dialysis become more mobile.For many long-term dialysis patients, the campervan will give them and their families an opportunity to go away within New Zealand and still be able to access treatment. 
Supplied/Waikato DHB Morrinsville Lions Club treasurer Bryan Barker, left, hands over a cheque for $110,000 to Waikato DHB clinical director Dr Peter Sizeland, with Waikato DHB clinical nurse manager Nicky Hagan and Lions Club member Hugh Makgill. Regional Renal Centre secretary Angela Eccles said the modified van was really about quality of life and improving many patients' mental health."For some patients they are hooked up to machines for six to eight hours every second day, this will at least give them the opportunity to still get that treatment but enjoy some time away from the hospital or home setting," she said.The van, an eight-seater Mercedes, will be stripped out and refitted as a campervan, complete with dialysis machine, which will used by patients with kidney damage or failure.Morrinsville Lions Club secretary Bryan Barker said this would allow dialysis patients to get away for a few days for a nominal fee. "When you see what these patients have to put up with, this is a very important project, " he said."The opportunity for dialysis patients to go away for even three days is a major exercise as those that have to go the hospital (for treatment) have to make arrangements for treatment at other locations, which is very difficult."With the club's donation, the van could now be purchased and modifications started while Lions continued to raise the rest of the funds, he said. It was hoped the van would be ready in July or August, he said.The funds were raised from donations, trust grants and club fundraisers.About 30 Lions club members cut firewood on a Morrinsville farm to sell, raising a total of $13,000 toward the project.There were also many donations from Lions clubs throughout the Waikato, King Country and Bay of Plenty districts, he said. - Stuff Next Hamiltons 150th story:
