* denotes detailed breakdown could not be found.<\/p>\n

We realize that this can seem somewhat abstract, so we have prepared two additional charts that graphically depict the star ratings that a consumer is likely to see while searching for providers and plans in two localities. Imagine an ESRD patient\u2019s caregiver, who may be a spouse over 65 or a son or daughter, who has also searched for or assisted a beneficiary in search of a Medicare Advantage plan. We expect that, owing to the complex needs of ESRD patients, this caregiver may also have searched for hospital and post-acute care provider ratings prior to or contemporaneous with a search for dialysis facility ratings.<\/p>\n

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The first graph depicts the distribution of star ratings a consumer will find in Dayton Ohio. Because of the greater weight given to health outcomes on DFC relative to other CMS rating systems, Ohio has disproportionate number of 1- and 2-star dialysis facilities; but this is not the case with other rated entities. The graph depicts the ratings of the first 12 entities that are listed on five CMS sites. (Home health ratings on our graphs are for patient experience\u2014Home Health Compare issues separate star ratings for clinical quality and patient experience.)<\/p>\n

Of the first 60 entities listed, 12 are below 3 stars and 29 are above 3 stars. Of the 12 entities with 2 stars or below, eight are dialysis facilities. Of the 29 entities with 3 \u00bd stars or above, none are dialysis facilities. To the beneficiary who has been exposed to the other CMS star systems (or for that matter, systems like safercars.gov or Yelp) the sight of solely 2- and 3-star facilities nearby will be jarring. While 4- and 5-star hospitals, post-acute providers and health plans are readily accessible in Dayton, the nearest 4-star dialysis facility is 21 miles north in Troy, Ohio.<\/p>\n

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The second graph depicts the distribution of star ratings in Springfield, Missouri. Because fewer than twelve rated home health agencies and MA plans are available in Springfield, this graph shows ten entities in each provider category and nine in the health plan category.<\/p>\n

Missouri is a state in which dialysis facilities are symmetrically distributed, and this pattern is seen in Springfield. However, the distributions of other entities skew to the high end as in Dayton: overall, 5 entities are below 3 stars while 28 are above. The effect of the distribution is to make 3-star entities look mediocre or laggard. This impression would be accurate with regard to most categories, since those star systems assign ratings above 3 stars to 41, 49, 49, and 60 percent of rated entities. But the impression is inaccurate with regard to dialysis facilities since 3 stars purports to mean \u201caverage\u201d and only 30 percent of facilities can earn ratings above that.<\/p>\n

To be clear, we expect such disparities in star rating systems to be a problem only in two thirds of the country. In the northwest, mountain west, upper Midwest and New England, the superior health of local populations skew DFC star ratings upwards so as to roughly match the skewing of the other rating systems.<\/p>\n

We believe CMS\u2019 other star rating systems appropriately convey a note of caution in identifying a small number of truly poor performers with one or two stars. They follow the conventions of movie reviews, Yelp, airline ratings, and other star systems familiar to the average consumer. It remains unclear to us why DFC was given a unique design nor why CMS would see a benefit to retaining its unusual design since dialysis patients and their caregivers are arguably the demographic group most likely to have reason to search multiple \u201cCompare\u201d websites and therefore experience confusion. We are therefore relieved that the Planned Changes document indicates that CMS will, at least for the immediate future, step away from this system.<\/p>\n

We want to emphasize that we do not dispute the normative considerations behind DFC\u2019s bell-curve distribution. We agree that ranking providers among their peers harnesses positive competitive dynamics and can provoke self-critical analysis among practitioners who all too typically believe themselves to be \u201cabove average.\u201d We believe, and we suspect that the DFC team agrees, that awarding 4- and 5-star ratings to 40 percent of facilities, and a greater percentage in the future, is a less-than-ideal outcome.<\/p>\n

Our concern has always been the disconnect between these idealized notions of rankings and the public\u2019s experience with and understanding of star ratings. Since we raised that initial objection 18 months ago, CMS has rolled out new star ratings or modified old star ratings that adhere to the common-understanding paradigm rather than to the idealized paradigm manifested in DFC\u2019s first iterations. As such, awarding four or five stars to 40 percent or more of dialysis facilities can be justified for purposes of harmonizing the various CMS programs, as well as conveying to consumers a sense, which we believe is accurate, that overall care is improving.<\/p>\n

Thank you for your consideration of our comments. As you\u2019ll recall, we had requested a meeting with you or Dr. Conway to discuss this matter in detail. We no longer feel an immediate need to hold such a discussion. However, if there are plans to revert to the bell-curve distribution in the near future we believe it would be helpful to gather and confer with the CMS personnel overseeing the various star rating systems to go over the disparities illustrated on the attached charts and seek a more uniform experience for consumers who visit CMS\u2019s website.<\/p>\n

Respectfully submitted,<\/p>\n

Jackson Williams
\nDirector of Government Affairs<\/p>\n<\/div>