Dialysis Patient Citizens has filed the first challenge to a Centers for Medicare & Medicaid Services quality program under the Data Quality Act, contending that the agency’s Dialysis Facility Compare (DFC) star ratings methodology fails to satisfy federal requirements for objectivity and utility in presenting information to the public.

The day after receiving the complaint, NORC at the University of Chicago emailed a notice to CMS’ Center for Clinical Standards & Quality and Dialysis Patient Citizens that said the organization is working with CMS to make improvements to the Dialysis Facility Compare website.

The notice said NORC at the University of Chicago, which is an independent social research organization, plans “to conduct discussions with users or potential users of this website to inform changes and improvements CMS is making.”

The Data Quality Act, enacted in 2001, created guidelines that govern how each federal agency compiles its data. Dialysis Patient Citizens’ complaint argues that the DFC star ratings fail the HHS Guidelines’ objectivity requirement because they are biased by the underlying population health of the area served by a dialysis facility, demonstrated by 63% of West Virginia dialysis facilities garnering 1- or 2-star ratings, double the national average. At the other extreme, 74% of Hawaii’s facilities earned 4- or 5-star ratings. West Virginia and Hawaii are generally recognized as America’s unhealthiest and healthiest state, respectively. According to Dialysis Patient Citizens, a regression analysis found that 24% of the variation among states’ proportions of 1- and 2-star facilities is explained by the life expectancy of the state’s overall population.

“We felt this challenge was necessary in light of CMS’ continued refusal to acknowledge that its quality ratings are distorted by socio-demographic factors,” said Jackson Williams, Director of Government Affairs for Dialysis Patient Citizens. “As is the case with Medicare Advantage star ratings and the hospital readmissions penalty, a clear geographic pattern is evident: New England, the Upper Midwest and Pacific regions score the highest, and the South and Greater Appalachia score the worst. However, the pattern with DFC is more exaggerated than in other quality programs, probably because dialysis facilities draw patients from more concentrated service areas.”

Dialysis Patient Citizens’ complaint also argues that the DFC star ratings fail the utility requirement by contradicting the public’s understanding of what “one-star” and “two-star” symbols mean. CMS has assigned those ratings to the 30% of facilities that rank the lowest, while conceding that a one-star rating does not mean a patient “will receive poor care from a facility.” Dialysis Patient Citizens cites the work of health care transparency expert Judy Hibbard in arguing that CMS’ refusal to apply the “inherent meaning” that consumers associate with 1- and 2-star ratings will result in patients being alarmed rather than informed.

“The public associates 1- and 2-star ratings with unacceptably low quality – they indicate that a product or service is not worth the consumer’s time or money,” said Hrant Jamgochian, executive director of Dialysis Patient Citizens. “That is not the case with dialysis, because the treatment is necessary to sustain the life of a patient with kidney failure. As a result, 1- and 2-star ratings should only be given to dialysis facilities that should close their doors, not to an arbitrary 30% of providers.”

A third section of the complaint contends that CMS did not follow proper procedures in formulating the DFC star ratings. CMS’ Information Quality Guidelines promise that tools for public use will be developed through a “collaborative process involving providers, consumers, academicians, and policy analysts;” however, while CMS is involving stakeholders in the formulation of its Hospital Compare star ratings by convening a Technical Expert Panel (TEP) with four consumer representatives, no TEP was convened for Dialysis Facility Compare star ratings.