CMS recently released the latest Care Compare refresh and for the second time they included hospital eCQM performance. The 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.
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:
Inpatient Quality Reporting (IQR) Program
Outpatient Quality Reporting (OQR) Program
Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Hospital Readmission Reduction Program (HRRP)
Hospital-Acquired Condition (HAC) Reduction Program
Hospital Value-Based Purchasing (HVBP) Program
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.
October 2023 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.
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.
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 timeframe of the data being displayed.
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.
Click the link "Download full dataset" (right side of your screen).
Unzip the file.
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.
2022 National Average
2022 Medisolv Clients
Safe Use of Opioids – Concurrent Prescribing (inverse measure)
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Discharged on Statin Medication
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis
Admit Decision Time to ED Departure Time for Admitted Patients - non psychiatric/mental health disorders
Admit Decision Time to ED Departure Time for Admitted Patients – psychiatric/mental health disorders
Heck yeah Medisolv Clients!! You all outperformed on almost every measure. We are so incredibly proud.
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.