Hospitals in More Stressed Cities Have Lower CMS Star Ratings

An analysis of 150 US cities’ stress rankings and the CMS star ratings of the hospitals within them reveals a significant correlation between the 2 factors, indicating that more-stressed cities tend to have lower hospital star ratings. The study, published in JAMA, also found associations between the star ratings and 4 of the 5 stress domains: work, money, family, and health and safety.

CMS star ratings incorporate 64 quality measures to assign ratings of 1 to 5 stars to hospitals across the United States. Large, teaching, and safety net hospitals are more likely to have lower star ratings, according to a CMS fact sheet announcing the ratings. The authors of the JAMA research thus decided to investigate whether these star ratings could be linked to city stress rankings.

Developed by WalletHub, the stress ranking of a city is determined by 27 key metrics across 5 domains: work, money, family, health and safety, and “stress-coping.” The measures used to assess these factors include the citywide rates of poverty, unemployment, divorce, crime, and residents in poor health. The findings pointed to Detroit, Michigan, as the #1 most stressed city, and Fremont, California, the least stressed as it ranked last at #150.

After creating a weighted average star rating for cities with more than 1 hospital, the researchers performed statistical analysis and found a significant correlation between the star rating and the city’s overall stress rating. In other words, a higher stress ranking (which indicates a less-stressed city) was associated with a higher hospital star rating. Cities with high stress, like Detroit or Newark, New Jersey, had relatively low star ratings, while cities like Madison, Wisconsin, with lower stress tended to have higher star ratings. The analysis also found significant associations between the star ratings and 4 of the 5 stress domains: work, money, family, and health and safety.

The researchers determined that around 20% of the variance in star ratings could be explained by community characteristics like unemployment or poverty. However, they expressed the need for further research on the causes of this correlation.

“On the one hand, hospitals in stressed cities might provide care of lower quality on average, perhaps because of inability to invest in needed clinical or technological infrastructure or staff shortages,” the authors wrote. “On the other hand, the star rating component measures may be affected by community factors such as poor public transportation or limited social support services through causal pathways other than hospital quality.”

This research points toward a larger body of evidence linking hospital star ratings to the economic well-being of the city, which some view as disproportionately punishing hospitals in low-income areas.

“It’s fine to penalize hospitals that provide bad care to poor people. We just don’t want to be penalizing hospitals that take care of more poor people,” said Ashish K. Jha, MD, MPH, in a recent interview with The American Journal of Managed Care. He said that that CMS could avoid this unfair penalization by including socioeconomic status in the risk adjustment methodology for star ratings.