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Conxita Jacobs-Cach, [email protected] These authors have contributed equally to this work and share first authorship Disclaimer All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers

Response: We acknowledge commenters' concerns about the staged process for the Overall Hospital Quality Star Ratings reductions, however more than 50 percent of hospitals already receive different ratings year-to-year just as a result of the evolution of the underlying data