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Hospital eCQM Results Are In: A Review of the January 2023 Care Compare Refresh


CMS recently released the latest Care Compare refresh and for the very first time hospital eCQM performance is publicized! But don't get too excited (or maybe do depending on your position), eCQM results are only in the downloadable data set, not published on the Care Compare website. Furthermore, CMS didn't provide a National or State eCQM performance. And, as always, it's impossible to find where this lives on the CMS website. Let us help you out a little bit here.

In this article, we review the basics of Care Compare, we provide national eCQM results and compare those to our clients' performance (<<spoiler, our clients rock), and we have an awesome resource for you. We've developed an Excel sheet download that explains exactly which measures are on Care Compare, which measures are used in the Star Ratings, and the timeframes reflected on the public website. Let's do it.

Overview

Care Compare is a public facing website that displays information about your hospital’s performance including a 1-5 Star Rating. It’s run by CMS and was previously called Hospital Compare.

You are probably somewhat aware that the measures you submit to the federal regulatory programs populate these public facing websites.

CMS uses your performance in these programs to populate Care Compare and the Star Ratings:

  1. Inpatient Quality Reporting (IQR) Program
  2. Outpatient Quality Reporting (OQR) Program
  3. Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
  4. Readmission Reduction Program (HRRP)
  5. Hospital-Acquired Condition (HAC) Reduction Program
  6. Hospital Value-Based Purchasing (HVBP) Program

RESOURCE

We’ve made an Excel sheet for you. The first tab has all measures used for Care Compare and the timelines of data currently used. The next two tabs contain information about which measures are used on the Care Compare website and which measures are used for the current Star Ratings.

CareCompare-2023-Update

 

Care Compare Workbook [Download]

 

Mapping Quality Measures to Care Compare

On Care Compare, you can enter your zip code or city/state and look up hospitals near you. I put in Baltimore, MD and up popped a list of surrounding hospitals.

stars-sc-1

You’ll notice before I even dive into the details, I can quickly see which hospitals have a better Star Rating and Patient Survey Rating.

Once you click into the individual facility, you see the hospital’s Star Rating and Patient Survey Rating called out again. Then, as you scroll, you see six accordions that contain more quality performance information.

CareCompare2023_Screenshot

You can click any of those quality categories and it will open a window with details on your hospital’s performance. Once opened, you’ll see the list of measures that CMS publicly displays on Care Compare. Download that resource above and look at the second tab. You'll see exactly which measures are used in the order that they appear (and with the modified description) and which reporting program they are part of.

Understanding Care Compare Timeframes

Now pay attention, this next part is important.

It’s important to know which measures are being displayed on Care Compare and it is as equally important to know the time frame of the data being displayed. You might be surprised to learn that most of the data released at the beginning of 2023 is your hospital's performance pre-pandemic. 

Of course, timeframes vary by measure. Furthermore, there are different timeframes for Care Compare measures versus the Star Ratings. Again - reference that resource I gave you in the beginning (first tab).

Here’s the last thing you must know about Care Compare. Not all measures are released at the same time. I assumed the quarterly refreshes of Care Compare released all publicly reported data. Not so. If you look at the Excel resource I made for you, it contains a column identifying which month(s) each measure is released. Please note, the Star Ratings are not really updated each quarter. In fact, CMS has only updated the Star Ratings once a year since their 2017 inception. The currently-published Star Ratings were released in July 2022. 

Where's my eCQM Performance?

Buried.

Let me show you how to find it.

  1. Visit this link: https://data.cms.gov/provider-data/dataset/4j6d-yzce.
  2. Click the link "Download full dataset" (right side of your screen).
  3. Unzip the file.
  4. Search for the file "Timely_and_Effective_Care-Hospital.csv" 

Or, because we love you, here is the file. [Download]

You'll note CMS did not release State or National averages. So here is a chart that shows the National average by eCQM along with our Clients' performance.

Measure ID
Measure Descripton
2021 National Average
2021 Medisolv Clients

SAFE_USE_OF_OPIOIDS

Safe Use of Opioids – Concurrent Prescribing (inverse measure)

18%

16%

STK_02

Discharged on Antithrombotic Therapy

95%

95%

STK_03

Anticoagulation Therapy for Atrial Fibrillation/Flutter

72%

82%

STK_05

Antithrombotic Therapy by End of Hospital Day 2

91%

92%

STK_06

Discharged on Statin Medication

93%

93%

VTE_1

Venous Thromboembolism Prophylaxis

85%

92%

VTE_2

Intensive Care Unit Venous Thromboembolism Prophylaxis

94%

95%

ED_2_Strata_1

Admit Decision Time to ED Departure Time for Admitted Patients - non psychiatric/mental health disorders

121

114

ED_2_Strata_2

Admit Decision Time to ED Departure Time for Admitted Patients – psychiatric/mental health disorders

191

256

 

Heck yeah Medisolv Clients!! You all outperformed on almost every measure. We are so incredibly proud.

Oh and one more thing. Medisolv's clients outperformed on the Safe Use of Opioids measure AND we represented 20% of nationwide submissions!

In Summary:

We hope this article and resource were helpful to you. It is really not easy to find or interpret this information. Quality leaders are often the ones responsible for monitoring and disseminating this information. It's important that as a quality leader, you know which measures are used to populate what the public sees on Care Compare. You should also understand the date ranges currently used so you can speak to it internally and to the public.

Consider focusing your future quality initiatives on improving any public reputation measures that look especially bad online and be sure to share your results internally (including your marketing team), so stakeholders understand the importance of your quality team’s initiatives and how they matter to your organization’s public reputation.

 
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.

 

 

 

 

Erin Heilman

Erin Heilman is the Vice President of Sales & Marketing for Medisolv, Inc.

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