The proportion of hospices that do not have a star rating from the U.S. Centers for Medicare & Medicaid Services (CMS) is growing.

CMS introduced the hospice star rating system in 2022 to help patients make informed decisions about which provider to choose. They appear on CMS’ Care Compare website. The scores are based on Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results.

Between August 2022 and that same month in 2024, the number of hospices without a star rating rose from 3,912 to 5,086, an average of 68%, according to a new study published in Health Affairs.

“Nearly two-thirds of Medicare hospices did not receive a star rating when CMS’s hospice star rating system was first introduced in 2022, and this pattern remained consistent through 2024,” the study authors wrote. “The purpose of the CMS hospice star rating is to allow patients to compare potential hospices in a way that is familiar and easy to understand. However, our work suggests a limited impact of the CMS hospice star rating system so far.”

A number of factors are contributing to this issue. For one, the number of hospices in the United States has been increasing. Also, many providers are ineligible for a star rating because they do not meet CMS reporting requirements. To be eligible, providers must have a minimum of 75 completed CAHPS surveys over an eight-quarter period. Some hospices can also receive an exemption based on size, such as if they have a patient census smaller than 50.

Hospices without a star rating were more likely to be for-profit, about 85.6%, the study found. They were also likely to have a smaller average daily census and lower Hospice Care Index scores compared to other providers. Close to 32% lacked a Hospice Care Index Score altogether.

The study authors made two recommendations to improve the rating system. First, they propose that CMS reconsider its criteria for the minimum number of completed CAHPS surveys necessary to receive a rating, as current thresholds may be unattainable for a large number of providers.

CMS may also want to consider implementing more than one rating system, according to the study. Home health providers, for example, have a star rating based on CAHPS scores and a second one founded on claims-based quality measures.

“Prior research has noted the importance of reporting two measures to meet the needs of stakeholders who may value different dimensions of care,” the study authors wrote. “Including a claims-based star rating may be informative, as other research has noted a discrepancy between agency-reported measures and claims-based measures; the former reported greater patient improvement after the introduction of home health star ratings.”