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Controversial Dialysis Facility Star Rating System Angers Patients

Posted by Reliant Renal Care

For patients in need of consistent dialysis treatment, finding the right treatment center is crucial in maintaining their health.  With the goal of aiding patients in the process of finding quality dialysis treatment centers, The Centers for Medicare & Medicaid Services (CMS) created the Dialysis Facility Compare star rating system, which ranked dialysis facilities nationwide on a 1-5 star scale, and made it available to the public on January 22nd of 2015, but not without critical flaws.

How the Star Rating System Works

The star rating system for dialysis facilities is based on nine quality measures:

  • Standardized Mortality Ratio (SMR)
  • Standardized Hospitalization Ratio (SHR)
  • Standardized Transfusion Ratio (STrR)
  • Percentage of adult hemodialysis (HD) patients who had enough wastes removed from their blood during dialysis
  • Percentage of pediatric hemodialysis (HD) patients who had enough wastes removed from their blood during dialysis
  • Percentage of adult peritoneal dialysis (PD) patients who had enough wastes removed from their blood during dialysis
  • Percentage of adult dialysis patients who had hypercalcemia
  • Percentage of adult dialysis patients who received treatment through arteriovenous fistula
  • Percentage of adult patients who had a catheter left in vein longer than 90 days for their regular hemodialysis treatment

With this data gathered from facilities around the country, Dialysis Facility Compare aimed to provide straightforward rating for dialysis patients to see the overall quality of the dialysis facilities near them, and find the best location for their needs.

The Controversy – Deceiving Ratings & The Bell Curve

As soon as the rating system was released, it met opposition from two national organizations who are major players in the dialysis patient community.  On January 26th, the American Kidney Foundation (AKF), one of the organizations that denounced the new rating system, stated that the outrage stems from the fact that the system “unfairly categorizes many facilities as low performers, in large part because the system ranks all dialysis facilities on a bell curve.”  This means that there were only a limited amount of star ratings for each level; 30% of the top facilities receive 4-5 stars, 40% receive 3 stars, and the remaining 30% that didn’t make it into those pools are stuck with a 1-2 star rating regardless of their actual dialysis treatment quality. The distribution is shown in the bell curve below.

Dialysis Facility Star Rating System

Ranking the facilities with this system is “forcing some facilities into the lowest 1 or 2 star ratings even when these facilities, in reality, provide excellent care” according to the AKF.

The Promise That Wasn’t Kept

The second major organization was Dialysis Patient Citizens (DPC), a patient led organization whose goal is to improve the quality of life for dialysis patients throughout the country. They spoke out against the star rating system, stating that they “are extremely disappointed that CMS appears to have reneged on an important promise it made last October, to inform Dialysis Facility Compare visitors that ‘a one-star rating does not mean you will receive poor care from a facility.”

In response to this complaint, the CMS added a section that briefly explains the star rating system and that 1-2 star ratings do not mean that the facility provides poor quality care. However, this information cannot be easily found unless patients are actively searching for it. Below is a screenshot of the Dialysis Facility Compare homepage with the link to the information about the star system highlighted with a red circle:


The information is marked with a small “new” banner, but it is still not obvious enough for users to see before they start searching for a dialysis facility.  Also, this information is only reachable through this main page, so it can’t be accessed while users use the search feature and looking at the list of rated facilities.

The Solution

Making the explanation of the star system more obvious is a quick fix to a larger problem. The Dialysis Patient Citizens organization suggests that the CMS “assigns star ratings using regional comparisons, rather than nationwide comparisons, so the ratings would reflect actual clinical quality and not a region’s underlying population health or other socio-demographic factors.” The also urged the CMS to only rate facilities with a 1-2 star rating if it offers poor quality services and should be avoided by dialysis patients.

The CMS chose to disregard the requests from the DPC, which led them to take the next step and file a Request for Correction under the Data Quality Act, in order to force the suggested modifications to be made to the Dialysis Facility Compare system.