September 04, 2018
4 min read

Analysis: Counting the stars: Who is the best among dialysis providers?

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On April 25, CMS published the latest data for its Dialysis Facility Compare Star Rating System for Medicare-certified dialysis facilities. The information is published on the Dialysis Facility Compare website ( compare). CMS developed the rating system in “response to a national call for greater transparency in how the agency measures the quality of kidney care.”1 The rating system has gone through several changes since CMS compiled its first report in January 2015, and more changes are planned for October when CMS changes the seven quality measures it has been using to determine the ratings (see Sidebar).

The rating system applies star ratings to those measures based on a point system; the higher your score, the more stars you achieve. One star is considered the worst rating and five is the best.

Mark Stephens

‘Stars’ come out

Within 1 to 2 business days of the ratings’ release, the larger dialysis organizations began publicizing their results. Fresenius Kidney Care said in a press release that it “has achieved the highest results in the industry” and “is the clear leader, achieving the highest percentage of four-and five-star rated clinics when compared to all other major dialysis providers in the country.”2 DaVita Kidney Care followed with a release stating it “has led the industry for the fourth year by meeting or exceeding Medicare standards” in the star rating system, and the results “mark DaVita’s best quality performance in the program to date.”3

To its credit, DaVita notes in its statement that improvements have been made throughout the industry in achieving more three-star to five-star ratings, although changes in the methodology for the rating system in recent years have likely increased star power for many providers.

Stars and measurement of quality

The question is: Who offers the best quality of care based on the star ratings?

Prima Health Analytics conducted an analysis of the latest star ratings, not only to verify the claims made by some dialysis companies, but also to shed some light on what other factors may influence results. We found that, subject to some caveats, none of the statements by the providers are false, per se, but more context might be useful to understand their value.

Claim: “Fresenius is the clear leader, achieving the highest percentage of four and five star-rated clinics when compared to all other major dialysis providers in the country.”

Reality: In our analysis looking at the top 10 largest dialysis companies (see Table 1), the organization with the highest percent of four and five-star rated facilities was Satellite Healthcare, with 70.5% of rated facilities receiving four or five stars. However, 25% of its clinics did not receive a star rating because these did not qualify.


Notes: The national percentage of dialysis facilities that achieved four or five stars is 53.4%. Fresenius has about 57% of rated facilities with four or five stars. Does this metric truly indicate who is the “clear industry leader?”

Claim: Fresenius wrote it had the largest number of facilities (659) achieving the highest rating, “the most in the industry.”

Reality: True, but what was not revealed is this organization also has the most one-star and two-star rated facilities in the industry (see Table 2).

Notes: The two largest dialysis organizations have roughly seven-to eight-times more facilities than the next largest provider. Using a measure of the absolute number of facilities with any particular score is not a good determinant of success.

Claim: “DaVita Kidney Care has led the industry for the fourth year by meeting or exceeding Medicare standards in the CMS Five-Star Quality Rating System.”

Reality: There is no specific measure of industry leadership in this statement to test. “Medicare standards” is a bit vague.

Claim: DaVita “has more three-, four- and five-star centers than it has ever had in the history of the program. The results mark DaVita’s best quality performance in the program to date.”

Reality: This may be true. However, the five-star scoring methodology was changed several years ago to eliminate the “bell curve” that limited higher star ratings. Our analysis shows the overall industry has seen a 26% increase in the percentage of facilities with at least three stars.

Notes: Arguably, the scoring methodology changed in such a way that the entire industry has seen grade creep softens the claim that the current star ratings represent the “best quality performance in the program to date.” More than half of all facilities nationally now boast four- or five-star ratings; whether that is because quality improved or the methodology for determing the ratings has changed is hard to say. Quality improvement year over year needs to be measured against a standard, not on a sliding scale. The upward trend in star ratings cannot be used as a valid measure of trends in quality of care.


Who is the best? Does it matter? Ultimately, the quality of dialysis care is measured at the local facility level. There are successes, and yet still work to be done. Until the organizations claiming to lead the industry in quality have eliminated the hundreds of one-star and two-star rated facilities that they own and operate, individual patient choice of where to receive this life-saving care cannot be based on the name of the parent company alone.