Medisolv Blog 2023 Star Ratings Calculation

2023 Star Ratings Calculation

2023 Star Ratings Calculation

CMS released the 2023 star rating for nearly all U.S. hospitals. The hospital star rating system began nearly a decade ago and is updated at least once annually. It uses a familiar system of ranking hospitals according to a star rating, with a one-star indicating poor performance and a five-star indicating excellent performance.

But while the star rating may be easy for consumers to understand, the calculation used to assess and rate hospitals is anything but simple. Today we will review how this star rating was calculated and how hospitals performed in 2023.

Which measures did CMS use for the 2023 star rating

The star rating is made up of five categories: mortality rates, patient readmissions to the hospital, safety of care, timely and effective care, and the patient experience (as reported by patients). Within each category are a set of measures which you have submitted through your various regulatory programs or CMS has gathered through your claim submissions. Here are the measures and timeframes that were used to determine your 2023 hospital star rating.

Star Ratings Measure Group

Measure ID

Measure name

Timeframe Used

Measure pulled from which program(s)

Mortality

 

MORT 30-AMI

Acute Myocardial Infarction (AMI) 30-Day Mortality Rate

July 1, 2018 -
December 1, 2019

HVBP

 

MORT 30-CABG

Coronary Artery Bypass Graft (CABG) 30-Day Mortality Rate

July 1, 2018 -
December 1, 2019

HVBP

 

MORT 30-COPD

Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality Rate

July 1, 2018 -
December 1, 2019

HVBP

 

MORT 30-HF

Heart Failure (HF) 30-Day Mortality Rate

July 1, 2018 -
December 1, 2019

HVBP

 

MORT 30-PN

Pneumonia (PN) 30-Day Mortality Rate

July 1, 2018 -
December 1, 2019

HVBP

 

MORT 30-STK

Acute Ischemic Stroke (STK) 30-Day Mortality Rate

July 1, 2018 -
December 1, 2019

IQR

 

PSI 04

Death Rate Among Surgical Inpatients with Serious Treatable Complications

July 1, 2019 -
December 31, 2019

IQR

Readmission

 

EDAC 30 AMI

Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction

July 1, 2018 -
December 1, 2019

IQR

 

EDAC 30 HF

Excess Days in Acute Care after Hospitalization for Heart Failure

July 1, 2018 -
December 1, 2019

IQR

 

EDAC- 30 PN

Excess Days in Acute Care after Hospitalization for Pneumonia (PN)

July 1, 2018 -
December 1, 2019

IQR

 

READM 30 CABG

Coronary Artery Bypass Graft (CABG) 30-Day Readmission Rate

July 1, 2018 -
December 1, 2019

HRRP

 

READM 30 COPD

Chronic Obstructive Pulmonary Disease (COPD) 30-Day Readmission Rate

July 1, 2018 -
December 1, 2019

HRRP

 

READM 30 HIP KNEE

Hospital-Level 30-Day All-Cause Risk- Standardized Readmission Rate (RSRR) Following Elective Total Hip Arthroplasty (THA)/Total Knee Arthroplasty (TKA)

July 1, 2018 -
December 1, 2019

HRRP

 

READM 30 HOSP WIDE

HWR Hospital-Wide All-Cause Unplanned Readmission

July 1, 2020 -
June 30, 2021

IQR

 

OP 32

Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

January 1, 2019 -
December 24, 2019

OQR

 

OP 35 ADM

Admissions for Patients Receiving Outpatient Chemotherapy

January 1, 2021 -
December 31, 2021

OQR

 

OP 35 ED

Emergency Department (ED) Visits for Patients Receiving Outpatient Chemotherapy

January 1, 2021 -
December 31, 2021

OQR

 

OP 36

Hospital Visits after Hospital Outpatient Surgery

January 1, 2021 -
December 31, 2021

OQR

Safety of Care

 

COMP HIP KNEE

Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA)

April 1, 2018 -
October 2, 2019,

HVBP

 

HAI 1

Central-Line Associated Bloodstream Infection (CLABSI)

April 1, 2021 -
March 31, 2022

HVBP, HACRP

 

HAI-2

Catheter-Associated Urinary Tract Infection (CAUTI)

April 1, 2021 -
March 31, 2022

HVBP, HACRP

 

HAI-3

Surgical Site Infection from Colon Surgery (SSI-colon)

April 1, 2021 -
March 31, 2022

HVBP, HACRP

 

HAI-4

Surgical Site Infection from Abdominal Hysterectomy (SSI-abdominal hysterectomy)

April 1, 2021 -
March 31, 2022

HVBP, HACRP

 

HAI-5

MRSA Bacteremia

April 1, 2021 -
March 31, 2022

HVBP, HACRP

 

HAI-6

Clostridium Difficile (C.difficile)

April 1, 2021 -
March 31, 2022

HVBP, HACRP

 

PSI 90

Patient Safety and Adverse Events Composite

July 1, 2019 -
December 31, 2019,

HVBP, HACRP

Patient Experience

 

H-COMP-1

Communication with Nurses

April 1, 2021 -
March 31, 2022

IQR, HVBP

 

H-COMP-2

Communication with Doctors

April 1, 2021 -
March 31, 2022

IQR, HVBP

 

H-COMP-3

Responsiveness of Hospital Staff

April 1, 2021 -
March 31, 2022

IQR, HVBP

 

H-COMP-5

Communication About Medicines

April 1, 2021 -
March 31, 2022

IQR, HVBP

 

Q 8 / Q 9

Cleanliness and Quietness of Hospital Environment

April 1, 2021 -
March 31, 2022

IQR, HVBP

 

H-COMP-6

Discharge Information

April 1, 2021 -
March 31, 2022

IQR, HVBP

 

H-COMP-7

Care Transition

April 1, 2021 -
March 31, 2022

IQR, HVBP

 

Q 18 / Q 19

Overall Rating of Hospital & Recommend Hospital

April 1, 2021 -
March 31, 2022

IQR, HVBP

Timely & Effective Care

 

HCP COVID-19

COVID-19 Vaccination Coverage Among HCP

January 1, 2022 -
March 31, 2022

IQR

 

IMM-3

Healthcare Personnel Influenza Vaccination

October 1, 2021 -
March 31, 2022

IQR

 

OP 10

Abdomen CT Use of Contrast Material

July 1, 2020 -
June 30, 2021

OQR

 

OP 13

Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery

July 1, 2020 -
June 30, 2021

OQR

 

OP 18b

Median Time from ED Arrival to ED Departure for Discharged ED Patients

April 1, 2021 -
March 31, 2022

OQR

 

OP 2

Fibrinolytic Therapy Received Within 30 Minutes of Emergency Department Arrival

April 1, 2021 -
March 31, 2022

OQR

 

OP 22

ED-Patient Left Without Being Seen

January 1, 2021 -
December 31, 2021

OQR

 

OP 23

ED-Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan Interpretation Within 45 Minutes of Arrival

April 1, 2021 -
March 31, 2022

OQR

 

OP 29

Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients

January 1, 2021 -
December 31, 2021

OQR

 

OP 3b

Median Time to Transfer to Another Facility for Acute Coronary Intervention

April 1, 2021 -
March 31, 2022

OQR

 

OP 8

MRI Lumbar Spine for Low Back Pain

July 1, 2020 -
June 30, 2021

OQR

 

PC 01

Elective Delivery Prior to 39 Completed Weeks Gestation: Percentage of Babies Electively Delivered Prior to 39 Completed Weeks Gestation

April 1, 2021 -
March 31, 2022

IQR

 

SEP 1

Severe Sepsis and Septic Shock

April 1, 2021 -
March 31, 2022

IQR, HVBP


There were two measures changes as compared to the previous star rating assessment. CMS retired OP-33 from the Timely and Effective Care category as of January 2022 and it is no longer part of your star ratings calculation. CMS added the HCP COVID-19 measures to the Timely Effective Care category for star rating calculation. Also, for the first time, the star rating included VA hospitals.

Additionally, CMS did modify some of the above timeframes based on COVID-19 impact to hospital performance. There were 15 measures (found in either the Mortality or Readmission category) that would normally include Q1 and Q2 2020 data but because of the pandemic they were excluded. Because of these changes, CMS calculated your star ratings using the majority of data (68%) to be reflective of your care after June 30, 2020.

Star Ratings Measure Availability

How Did CMS Calculate the 2023 Hospital Star Rating?

The star rating calculation was simplified in 2021 and now is calculated in 10 steps.

STEP 1: Hospitals submit data to CMS quality programs

You, as a hospital, go about your business of submitting measures to the CMS quality programs: Hospital IQR, OQR, Readmission Reduction, HAC Reduction and HVBP programs. See programs referenced above. Sometimes you submit the measure (like SEP-1) and sometimes CMS collects the data from claims files.

STEP 2: CMS identifies which measures and timeframes to use

CMS selects which measures they will use to make the star rating score. The measures used in the 2023 star rating are listed above.

STEP 3: CMS standardizes the measure scores

CMS takes your hospital’s performance on those CMS-selected measures and standardizes the measure score so it makes sense in the overall equation. Think about an inverse measure where lower scores are better. You wouldn’t want that score to count against a total score, so they standardize all measure scores. This method of standardizing is called Z-scoring.

Understanding Z-scoring

A Z score is statistical technique. It’s a standard deviation score which shows the amount of variation in a dataset. For the star rating, Z-scores were produced by subtracting the national mean score from each hospital’s measure score and dividing that by the standard deviation across hospitals. Standard deviation is a number that measures how far data values are from their average.

ZScoring Example

In addition to that, CMS changed the direction of all inverse measures to reflect better performance for those lower scores.

STEP 4: Measures are grouped

The measures are put into groups based on the category. The five measures groups are:

  1. Mortality
  2. Safety of Care
  3. Readmissions
  4. Patient Experience
  5. Timely and Effective Care

STEP 5: CMS calculates the measure group score using a simple average

In each measure group, CMS will calculate a simple average to determine a measure group score. A simple average takes the sum of measures with equal weights and divides by the number of measures a hospital reports.

For example:

There are 8 measures in the Safety of Care category.

100 divided by 8 is 12.5 so each of the 8 measures in this category would be worth 12.5% of the overall Safety of Care category score.

100% / 8 measures = 12.5%
Measure group score (based on example above) =
[(-1.13*0.125) + (-0.75*0.125) + (0.09*0.125) + (1.21*0.125) + (0.97*0.125) + (0.98*0.125) + (0.46*0.125) + (0.02*0.125)] = 0.23

Star Ratings Category Score Example

STEP 6: CMS applies a weight to each group score

Not all categories are weighted evenly. A weight is applied to that measure group score. Your final score is calculated according to the weight of the category. The weights for the five categories are as follows:

  • Mortality = 22% weight
  • Safety of Care = 22% weight
  • Readmissions = 22% weight
  • Patient Experience = 22% weight
  • Timely and Effective Care = 12% weight

For Example:

Summary score = [(-0.70*0.22) + (0.23*0.22) + (-0.76*0.22) + (-1.13*0.22) + (-0.25*0.12)] = -0.55

CMSStar Rating Overall Score Example

STEP 7: Hospitals are excluded, or their score is re-weighted depending on the number of measures submitted

Not all hospitals submit (or have enough claims) to qualify for every measure in all five categories. A hospital must report at least three measure groups with at least three measures in each group, (must include groups Mortality or Safety of Care) in order to receive a star rating. Once the minimum measure and measure group thresholds are met, any additional measures a hospital reports would be included in the star rating calculation.

Let’s say you met the minimum threshold, but you didn’t have any measures that were able to be calculated in the Timely and Effective Care category. That measure group is subtracted from the total.

For Example:

100 (100-12=88)

Mortality weight: 22/88 = 25%
Safety of Care weight: 22/88 = 25%
Readmission weight: 22/88 = 25%
Patient Experience weight: 22/88 = 25%

Example of Reweighting for a Hospital Which Does Not Report Timely and Effective Care Measure Group

ReweightingNoTimelyCareScoreStarRating[88]

STEP 8: Hospitals are put into one of three peer groups based on the number of measures they submitted

Hospitals are put into one of three peer groups depending on how many measures they submit or are calculated. CMS believes that by grouping hospitals by how many measure groups they report, this will help capture key differences between hospitals like size, patient volume, case mix and service mix. Larger hospitals, for example, generally submit the most measures and smaller hospitals submit the fewest.

The three peer groups are:

  1. Five measure groups submitted
  2. Four measure groups submitted
  3. Three measure groups submitted

STEP 9: Within the peer groups, scores are split into 5 groups using the k-means clustering method

Within the peer grouping, scores are split into five groups using the k-means clustering method. Essentially the k-means clustering is an algorithm method which aims to make hospital scores results within a cluster more similar to each other than to a different cluster.

STEP 10: whichever group your score puts you in becomes your star rating

Whichever k-means clustering group your score puts you in becomes your star rating.

Note: Since hospitals in a peer group are being compared only to each other that means hospitals with the same score, but a different peer group, could receive different star ratings.

How Did Other Hospitals Perform?

There were 3,076 hospitals who received a star rating in 2023 as compared to 3,122 hospitals in 2022.

This year:

  • 250 (8%) got 1 star
  • 668 (22%) got 2 stars
  • 872 (28%) got 3 Stars
  • 803 (26%) got 4 stars
  • 483 (16%) got 5 stars

The distribution of star ratings is similar to the distribution in 2022.

Star Ratings Distribution

Medisolv had 117 of the 438 5-star hospitals. Congratulations to all of our 5-star hospitals listed below.

How to Improve Your Star Rating

If you made it this far down in the article, congratulations; you are one step closer to improving your star rating. Simply by understanding how the star rating is calculated and what timeframes they consider will help you to understand what to focus on.

It comes down to ensuring you are doing everything you can to improve your performance across the major regulatory programs I mentioned in Step 1: Hospital IQR, OQR, Readmission Reduction, HAC Reduction and HVBP programs.

These measures are used for more than just star rating calculation, they are publicly reported on Care Compare. The public facing website contains not just the measures from your star ratings, but a whole host of additional measures submitted in those regulatory programs. Furthermore, the Care Compare measures are used, at least in part, for almost every public hospital ranking program today. Some popular programs are the U.S. World and News Reports for Best Hospitals and the Leapfrog Hospital Safety Grades which assigns letter grades for all hospitals.

The number of stars and your public performance may influence the credibility, efficiency, culture, and financial state of your organization.

Congratulations to Medisolv's 5-Star Hospitals:

Mayo Clinic Hospital - Arizona Buffalo Hospital
UC San Diego Medical Center Mayo Clinic Health System - Mankato
Sharp Grossmont Hospital M Health Fairview Woodwinds Hospital
UCLA Health - Santa Monica Medical Center Baptist Memorial Hospital - Union County
Ronald Reagan UCLA Medical Center Baptist Memorial Hospital - Leake
Goleta Valley Cottage Hospital Missouri Baptist Medical Center
Community Memorial Hospital - Ventura Saint Lukes Hospital of Kansas City
Santa Barbara Cottage Hospital Barnes-Jewish St Peters Hospital
University of California San Francisco Health System  Saint Lukes East Hospital
UCSF Helen Diller Medical Center at Parnassus Heights Progress West Hospital 
Keck Hospital of USC  Hedrick Medical Center
Whittier Hospital Medical Center Cox Monett Hospital
Greater El Monte Community Hospital Bryan East Campus
UCHealth Poudre Valley Hospital Bellevue Medical Center
UCHealth University of Colorado Hospital Exeter Hospital
UCHealth Medical Center of the Rockies Hackensack University Medical Center
MidState Medical Center Morristown Medical Center
Lee Memorial Hospital NewYork-Presbyterian Queens
Baptist Medical Center Nassau NewYork-Presbyterian Weill Cornell Medical Center
Mayo Clinic Hospital - Florida Tisch Hospital
St Lukes Boise Medical Center NYU Langone Health 
Evanston Hospital (AKA NorthShore Evanston Hospital) Duke University Hospital
Rush Oak Park Hospital Watauga Medical Center
Northwestern Medicine McHenry Hospital  UNC Medical Center 
Rush University Medical Center Duke Raleigh Hospital
Carle BroMenn Medical Center  UNC Rex Hospital 
Northwestern Medicine Lake Forest Hospital Wake Forest Baptist Health - Davie Medical Center
Northwestern Medicine Delnor Hospital Novant Health Mint Hill Medical Center
Northwestern Medicine Central DuPage Hospital The Outer Banks Hospital
Northwestern Memorial Hospital Essentia Health - Fargo 
Northwestern Medicine Kishwaukee Hospital  OhioHealth OBleness Hospital
IU Health North Hospital Wooster Community Hospital
Boone County Hospital OhioHealth Dublin Methodist Hospital
The University of Kansas Hospital Surgical Hospital at Southwoods (AKA Southwoods Health)
Saint Lukes South Hospital INTEGRIS Health Grove Hospital
St Tammany Health System  OHSU Hospital - Portland (AKA OHSU Hospital - Marquam Hill Campus)
UM St Joseph Medical Center  Bryn Mawr Hospital
Mount Auburn Hospital Doylestown Hospital (AKA Doylestown Health)
Massachusetts General Hospital South County Hospital
Emerson Hospital Miriam Hospital
Milford Regional Medical Center Prisma Health Patewood Hospital 
Winchester Hospital Sanford USD Medical Center
Beth Israel Deaconess Hospital - Milton  North Texas Medical Center
Brigham and Womens Hospital Methodist Hospital Hill Country 
Lahey Hospital & Medical Center - Burlington  Memorial Hermann Sugar Land Hospital
Spectrum Health Zeeland Community Hospital University of Utah Hospital
MyMichigan Medical Center Alpena The University of Vermont Medical Center 
Spectrum Health Butterworth Hospital Southwestern Vermont Medical Center
Spectrum Meijer Heart Center Porter Medical Center
University Hospital University Hospital
UP Health System - Portage Main Campus Carilion Giles Community Hospital
Sparrow Eaton Hospital  Mayo Clinic Health System - Franciscan Healthcare La Crosse
Spectrum Health Gerber Memorial Mayo Clinic Health System - Eau Claire
Essentia Health - St Marys Medical Center Howard Young Medical Center
Mayo Clinic Hospital - Saint Marys Campus University Hospital
Essentia Health - Duluth  Mayo Clinic Health System - Northland in Barron
Cambridge Medical Center Mayo Clinic Health System - Red Cedar in Menomonie
Mayo Clinic Health System - Albert Lea ThedaCare Medical Center - Berlin
Abbott Northwestern Hospital  

 

Sources:
i. 
https://public-inspection.federalregister.gov/2020-26819.pdf
ii. 
https://www.aha.org/system/files/media/file/2020/12/cms-issues-hospital-outpatient-asc-final-rule-including-maintenance-340b-cuts-bulletin-12-3-20.pdf
iii. 
https://www.sheppardhealthlaw.com/2020/12/articles/centers-for-medicare-and-medicaid-services-cms/new-criteria-hospital-quality-star-rating/
iv. 
https://qualitynet.cms.gov/inpatient/public-reporting/overall-ratings/data-collection


 
Medisolv Can Help 

Along with award-winning software, each client receives a dedicated Clinical Quality Advisor that helps you with your technical and clinical needs.

We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Especially if you use an EHR vendor right now, you’ll notice a huge difference.

  • We help troubleshoot technical and clinical issues to improve your measures.
  • We keep you on track for your submission deadlines and ensure you don’t miss critical dates.
  • We help you select and set up measures that make sense based on your organization's situation.
  • You receive one advisor that you can call anytime with questions or concerns - no limit on hours.

Contact us today.

 

 

 

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