In an effort to make comparing hospitals more like shopping for refrigerators and restaurants, the federal government has awarded its first star ratings to hospitals based on patients’ appraisals.

Many of the nation’s leading hospitals received middling ratings, while comparatively obscure local hospitals and others that specialized in lucrative surgeries frequently received the most stars.

Evaluating hospitals is becoming increasingly important as more insurance plans offer patients limited choices. Medicare already uses stars to rate nursing homes, dialysis centers and private Medicare Advantage insurance plans. While Medicare publishes more than 100 quality measures about hospitals on its Hospital Compare website, many are hard to decipher, and there is little evidence consumers use the site very much.

Many in the hospital industry fear Medicare’s five-star scale won’t accurately reflect quality and may place too much weight on patient reviews, which are just one measurement of hospital quality. Medicare also reports the results of hospital care, such as how many died or got infections during their stay, but those are not yet assigned stars.

“There’s a risk of oversimplifying the complexity of quality care or misinterpreting what is important to a particular patient, especially since patients seek care for many different reasons,” the American Hospital Association said in a statement.

Medicare’s new summary star rating, posted Thursday on its Hospital Compare website, is based on 11 facets of patient experience, including how well doctors and nurses communicated, how well patients believed their pain was addressed, and whether they would recommend the hospital to others. Hospitals collect the reviews by randomly surveying adult patients – not just those on Medicare — after they leave the facility.

In assigning stars, Medicare compared hospital against each other, essentially grading on a curve. It noted on its Hospital Compare website that “a 1-star rating does not mean that you will receive poor care from a hospital” and that “we suggest that you use the star rating along with other quality information when making decisions about choosing a hospital.”

Nationally, Medicare awarded the top rating of five stars to 251 hospitals, about 7 percent of all the hospitals Medicare judged, a Kaiser Health News analysis found. Many are small specialty hospitals that focus on lucrative elective operations such as spine, heart or knee surgeries. They have traditionally received more positive patient reviews than have general hospitals, where a diversity of sicknesses and chaotic emergency rooms make it more likely patients will have a bad experience.

A few five-star hospitals are part of well-respected systems, such as the Mayo Clinic’s hospitals in Phoenix, Jacksonville, Fla., and New Prague, Minn. Mayo’s flagship hospital in Rochester, Minn., received four stars.

Medicare awarded three stars to some of the nation’s most esteemed hospitals, including Cedars-Sinai Medical Center in Los Angeles, NewYork-Presbyterian Hospital in Manhattan, and Northwestern Memorial Hospital in Chicago.  The government gave its lowest rating of one star to 101 hospitals, or 3 percent.

On average, hospitals scored highest in Maine, Nebraska, South Dakota, Wisconsin and Minnesota, KHN found. Thirty-four states had zero one-star hospitals.

Hospitals in Maryland, Nevada, New York, New Jersey, Florida, California and the District of Columbia scored lowest on average. Thirteen states and the District of Columbia did not have a single five-star hospital.

In total, Medicare assigned star ratings to 3,553 hospitals based on the experiences of patients who were admitted between July 2013 and June 2014. Medicare gave out four stars to 1,205 hospitals, or 34 percent of those it evaluated. Another 1,414 hospitals—40 percent— received three stars, and 582 hospitals, or 16 percent, received two stars. Medicare did not assign stars to 1,102 hospitals, primarily because not enough patients completed surveys during that period.

While the stars are new, the results of the patient satisfaction surveys are not. They are presented on Hospital Compare as percentages, such as the percentage of patients who said their room was always quiet at night. Often, hospitals can differ by just a percentage point or two, and until now Medicare did not indicate what differences it considered significant.  The Centers for Medicare & Medicaid Services (CMS) also uses patient reviews in doling out bonuses or penalties to hospitals based on their quality each year.

Some groups that do their own efforts to evaluate hospital quality questioned whether the new star ratings would help consumers. Evan Marks, an executive at Healthgrades, which publishes lists of top hospitals, said it was unlikely consumers would flock to the government’s rating without an aggressive effort to make them aware of it.

“It’s nice they’re going to trying to be more consumer friendly,” he said. “I don’t see that the new star rating itself is going to drive consumer adoption. Ultimately, you can put the best content up on the Web, but consumers aren’t going to just wake up one day and go to it.”

Jean Chenoweth, an executive at Truven Health Analytics, which also publishes its own list of top hospitals, said she feared hospital marketing departments would oversell the meaning of the stars.  “It would be very unfortunate and misleading if a hospital marketing department could claim to be a CMS five-star hospital and fail to mention it only reflected a patients’ perception of care,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Anne Koller was diagnosed with late-stage colon cancer in 2011 and has been fighting it since.

But it’s not just the cancer she’s fighting. It’s the bills.

“Think of those old horror flicks,” she says. “The swamp creature … comes out and is kind of oozy, and it oozes over everything.”

Koller, who lives in the Cleveland suburb of Strongsville, just turned 65 years old. She is petite and sports a stylish auburn wig. When she was able to work, Koller was in the corporate world and safely middle-class, with health insurance and plenty of savings.

But when she got sick, her high deductible health plan soon became a burden. And her monthly premiums kept increasing, reaching nearly double her mortgage payment. She soon found herself unable to keep up with the bills. They piled up.

“You start looking at these bills,” Koller says, “and, as much as you know it’s expensive, the shock itself is like, ‘What?’”

Her response was to begin asking her doctors about the cost of the treatments they recommended and whether there was a less expensive alternative.

Middle-income patients are — more than ever — feeling the pressure of that financial burden, says Dr. Neal Meropol, an oncologist at University Hospitals in Cleveland. He took over Koller’s care a couple of years ago.

“Patients are weighing this in their calculus now,” Meropol says.

He blames high-deductible health plans and soaring prices for a new generation of drug therapies that came onto the market in the late 1990s.

“We went from drugs that cost a few hundred dollars for a course of therapy that might be a month or six months or a year, to drugs that were costing $10,000 a month,” Meropol says.

Total cost of cancer care in the United States is projected to reach more than $150 billion by 2020, according to the National Cancer Institute. The U.S. Centers for Disease Control and Prevention released a study last year that found that, compared to people without a cancer diagnosis, cancer survivors are less likely to work and more likely to struggle financially. Another study, out of Washington state, found that the longer a cancer patient survived, the higher the rate of bankruptcy.

University of Chicago’s Dr. Jonas de Souza argues that it’s time for oncologists to begin considering the financial consequences as a real side effect to cancer care.

“We talk about hair loss,” de Souza says. “We talk about numbness and tingling in the hands and feet. We talk about, ‘This chemotherapy will cause low blood counts.’ Right. Should we also be talking about, ‘Well, this chemotherapy is expensive?’ ”

He and Meropol are part of a growing field of researchers studying the impact of costs for cancer patients.

Anne Koller will tell you cancer does cause financial stress.

“Here’s what happens,” Koller says. “I was talking about that swamp thing … but you know, OK, you go to collections. You end up with a court thing. I had been talking to the hospital, asking for help — nothing, nothing. Finally, they went to a sliding payment scale.”

Her credit is ruined. So she continues to drive an old car. Small expenses, like an Internet connection, are out of the question. And there are other challenges.

“Socially, things change a lot,” she says. “You talk to people and, if you dare, say, ‘God, you know, I can’t afford this,’ for instance.” And there is little money for niceties, she said. If someone suggests, “‘Let’s go out to lunch,’ on the day you can eat. You … think twice about it.”

Koller says she wishes more financial information had been given earlier in her treatments. She is now using the very last of her savings to pay bills — and, still, some are going unpaid.

This story is part of a reporting partnership that includes WCPN/Ideastream, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Earlier this year, Caryn Hoadley received an unexpected letter after a routine mammogram.

The letter said her mammogram was clean but that she has dense breast tissue, which has been linked to higher rates of breast cancer and could make her mammogram harder to read.

“I honestly don’t know what to think about the letter,” said Hoadley, 45, who lives in Alameda, Calif. “What do I do with that information?”

Millions of women like Hoadley may be wondering the same thing. Twenty-one states, including California, have passed laws requiring health facilities to notify women when they have dense breasts. Eleven other states are considering similar laws and a nationwide version has been introduced in Congress.

The laws have been hailed by advocates as empowering women to take charge of their own health. About 40 percent of women have dense or extremely dense breast tissue, which can obscure cancer that might otherwise be detected on a mammogram.

But critics say the laws cause women unnecessary anxiety and can lead to higher costs and treatment that doesn’t save lives or otherwise benefit patients.

“While I think the intent of these laws is well meaning, I think their impact is going to be a significant problem, where we end up doing more harm than good,” said Dr. Laura Esserman, a University of California-San Francisco surgeon and breast cancer specialist.

Typically, the laws require a notice be sent to a woman if she has dense breast tissue seen on a mammogram. Some notifications suggest that a woman talk to her doctor about additional screening options.

But in some states, not including California, the laws go further by requiring health providers to offer a supplemental screening like an ultrasound to women with dense breasts even if their mammograms are clean. Connecticut, Illinois and Indiana even require insurers to pay for screening ultrasound after mammography if a woman’s breast density falls above a certain threshold.

Otherwise insurers do not routinely cover supplemental screening for women with clean mammograms, even if they have dense breasts. The Affordable Care Act does not require it.

The problem, Esserman says, is that no medical consensus exists on whether routine supplemental screening for women with dense breasts is worthwhile.

A recent Annals of Internal Medicine study using computer modeling found that offering an ultrasound to women with dense breasts after a clean mammogram would not significantly improve breast cancer survival rates but would prompt many unnecessary biopsies and raise health care costs.

Another study conducted in Connecticut after its notification law went into effect found that supplemental ultrasound screening for women with dense breasts did find a few additional cancers – about three per 1,000 women screened – but the probability that such screenings would find life-threatening cancers was low.

Dense breast notification laws have added another layer of complexity to the long-running and often emotional debate over how best to screen women for breast cancer.

Breast cancer is the second most common form of cancer among American women, behind skin cancers, and the second leading cause of cancer death. An estimated 231,840 U.S. women will be diagnosed with invasive breast cancer in 2015, according to the American Cancer Society.

About 38.5 million mammograms are performed each year in an attempt to find signs of cancer early enough to treat it successfully. Emerging technologies like tomosynthesis, a 3-D digital X-ray of the breast, may become cheap enough to replace conventional mammography and make the notification laws irrelevant, but their widespread use is years away.

For a long time, women were advised to start yearly mammograms at about age 40, but in 2009, the U.S. Preventive Services Task Force issued controversial recommendations that most women without a family history of breast cancer or other risk factors should wait until age 50 to begin mammograms, and repeat them every two years. Patient advocates decried the recommendations as “rationing” preventive health care for women.

In the meantime, Nancy Cappello, an education administrator from Connecticut, was pushing to pass what became the nation’s first dense breast notification law. Just two months after a clean mammogram, she had been diagnosed with breast cancer that had spread to her lymph nodes.  She had extremely dense breasts, something her radiologist knew but Cappello was not told. Dense breasts have more glandular and fibrous tissue, which block the X-rays used in mammograms more than fatty tissue does.

Eventually, she founded the patient advocacy organization  and took her campaign national.

“There’s no evidence that we’re scaring women. Most women I’ve talked to are very happy to get these notifications,” said Cappello, whose cancer is in remission. “We want to make informed decisions…to have a better chance of surviving the disease.”

Dr. Jane Kakkis, a breast cancer surgeon in Fountain Valley, Calif., supports dense breast notification laws and testified in front of Nevada lawmakers before that state passed its law in 2013. Like Cappello, she dismisses concerns that the notification laws will cause undue fear.

“You have no idea what fear is until you have a cancer that’s already spread to your lymph nodes,” Kakkis said. “Patients will say in disbelief, ‘but I just had a mammogram and it was normal.’ They can’t believe how advanced it is. Dense breast notification is bringing up a whole conversation about risk that wouldn’t come up otherwise.”

One of Kakkis’ patients, Catharine Becker of Fullerton, was diagnosed with breast cancer six years ago. She’d felt a lump three months after a clean mammogram. Because Becker had a family history of breast cancer – her mother died from the disease – she started mammograms early, at age 35. But they never showed any cancer. Until she was diagnosed, she didn’t know she had dense breast tissue.

“To be told at age 43 I had stage 3 cancer after a clean mammogram was really a shock,” Becker said, crediting her survival to breast self-exam and her doctors. “I’d rather have more information than less.”

Women with moderately dense breasts have about a 20 percent higher chance of getting breast cancer than women who don’t. Those with the highest-density breasts have about double. To put these numbers into perspective, if an average 50-year-old woman has a 2.38 percent chance of getting cancer in the next 10 years of her life, a woman with the highest density breasts would have a 4.76 percent chance of being diagnosed.

New ways of classifying dense breast tissue could put even more women in the category of receiving dense breast notifications, said Dr. Priscilla Slanetz, who recently wrote a New England Journal of Medicine article questioning the effectiveness of dense breast notification laws.

One reason she wrote the article, she said, was “in our state [Massachusetts] very few of our primary care providers have any knowledge about breast density and strengths and limitations of these different tests” for supplemental screening.

The same may hold true in California, where a small survey of primary care doctors found that only half of them had heard of the state’s 2013 dense breast notification law and many felt they didn’t have enough education to address what breast density meant for their patients.

On this point, both supporters and critics of the laws agree: doctors need better tools to help their patients identify their individual cancer risks.

To that end, specialists are developing more personalized screening protocols that result in low-risk women being screened less often than higher-risk women.

“It’s not rationing, it’s being rational,” said Esserman, who has a $14 million grant to study the issue.   “We should be testing different approaches for screening women with dense breasts, and then pass legislation once we know what to do.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Statement from Secretary Burwell on the introduction of Bipartisan Trade Promotion Authority