Why should you read this post?
- Will patients travel to or away from your hospital based on its CMS star rating?
- Potential patients indicate a willingness to travel long distances for higher rated care (Trenaman et al., 2024).
- Systematic differences exist in the number and rate of 5-star hospitals in each state.
- Increased patient experience and readmission performance are strongly related to higher rates of 5-star hospitals.
At the end of July, the Centers for Medicare and Medicaid Services (CMS, 2024a) released their latest version of the hospital Overall Ratings, also known as stars. The stars program is meant to provide one public-friendly measure of quality for selecting hospitals for care (Oddleifson et al., 2022). This Overall Rating is publicly published on each hospital’s profile on CMS’ Care Compare website.
Patients want to receive care at high quality hospitals. Recently, researchers Trenaman and colleagues (2024) surveyed Medicare beneficiaries and found that these potential patients would be willing to pay almost $1,700 more for their care at hospitals with an additional star. More importantly because of Medicare price contracting, these potential patients were willing to travel an additional 695 miles for care at a 5-star hospital versus a 1-star hospital. This distance certainly suggests many patients are willing to travel beyond state lines for high quality care.
If potential patients are willing to travel beyond state lines for the best care, does the public reporting of hospital quality-of-care look different from state to state? If so, what should hospitals in states with less 5-star hospitals focus on to improve their scores?
Our goal for this blog post is to share if there are differences in the number and rate of hospitals receiving 5-stars by state. For this post, we used the July 2024 overall ratings data (CMS, 2024a). Additionally, we analyzed the underlying factors that contributed to each hospital’s star rating which is only found in CMS’ (2024b) release of the Overall Rating SAS software. Combining these data sets allowed us to share with you the quality measure domains that were strongly related to a higher rate of 5-star hospitals in a given state.
The 5-Star Hospital Map: State-by-State Breakdown
California, Texas, and Pennsylvania have the most 5-star hospitals of any state or U.S. territory. At the other end, Alaska and New Mexico are states that have no 5-star hospitals from this release. Also, the territories of Washington D.C., Puerto Rico, Guam, and the Virgin Islands also have no 5-star hospitals.
See Figure 1 for an interactive map of the United States where each state is color coded based on the number of 5-star hospitals in the state.
The fact that California and Texas have the most 5-star hospitals may be less interesting given that they also have the most hospitals that received ratings from CMS. If 5-star hospitals were evenly distributed then this would be a matter of fact. However, the rate of 5-star hospitals across the states is not evenly distributed.
Higher Rate of 5-star Hospitals in Neighboring States
On average, 13% of hospitals received a 5-star rating out of the 2,834 hospitals that received any rating at all. The rate of 5-star hospitals within states ranges from 0% to 50%. Almost 50% of the hospitals rated in Utah and South Dakota are rated as 5-star hospitals.
See Figure 2 for an interactive map of the United States where each state is color coded based on the rate of 5-star hospitals.
While there is some geographic pattern to which states have more 5-star star hospitals, there are exceptions. In general, Midwestern states have a higher rate of 5-star hospitals. The exceptions are North Dakota (12.5%) and Illinois (10.2%) which have less than average rates of 5-star hospitals.
Behind the Stars: Relationships with Quality Domains
An important question is what is driving the state-by-state variability of 5-star hospitals. An initial investigation into this observation can be found by looking at the state performance of the domains of quality that make up the Overall Rating.
The overall rating is a composite of five domains. Four of the domains are weighted 22% each: Mortality, Readmissions, Safety, and Patient Experience. The last domain of Efficiency & Effectiveness makes up the last 12% of the score.
See Figure 3 for an interactive scatterplot of the rate of 5-star hospitals in a state and each of these domains. Use the highlight tool to find the point for your state.
The relationship varies between the rate of 5-star hospitals in a state and the state average performance in these individual domains. The strongest correlation coefficient (r = 0.682) was between the state-wide performance on Patient Experience and the rate of 5-star hospitals. The strength of the relationship with Readmissions was also similar to Patient Experience. The weakest correlation coefficient (r = 0.248) was between the state-wide performance on Safety and the rate of 5-star hospitals. All correlation coefficients were statistically significant.
- States with hospitals that collectively did better on patient experience or readmissions tended to have a higher rate of 5-star hospitals.
- The relationship between doing better on mortality, safety, and efficiency was more weakly associated with a high rate of 5-star hospitals.
Pushing the Boundaries: Next Steps for Hospital Ratings by State
The CMS data alone is limited in its ability to answer why these relationships exist. A deeper dive into the states may provide some answers to the existence of these relationships. State policy and regulation can influence healthcare provider performance within their state (Kissam et al., 2019). Because of this, states may influence hospital performance on healthcare quality ratings.
Additional research is needed to understand if there are systematic differences in how well hospitals perform on patient experience and readmissions based on the state. Research questions could include:
- Could performance in these areas be influenced by state healthcare policy?
- Are there state-wide initiatives supporting the healthcare ecosystem in that state, particularly supporting patient experience or readmissions?
- Is there a greater concentration within certain states of health systems who are more focused on achieving high quality?
From Analysis to Action: Elevating Your Hospital’s Star Rating
This analysis of CMS’s latest hospital Overall Ratings (stars) reveals noticeable variations in the distribution of 5-star hospitals across states. This investigation suggests that patient experience and readmissions are strongly related to a state’s rate of top-rated hospitals. This finding raises important questions about state-level factors influencing hospital quality, such as specific policies or healthcare initiatives.
These state-level variations offer valuable insights for healthcare providers, policymakers, and advocates. They suggest that focusing on patient experience and reducing readmissions could be key strategies for hospitals aiming to differentiate themselves and achieve a 5-star rating. Further research into state-specific factors influencing hospital quality could help improve healthcare equity and ensure patients have access to high-quality care regardless of their location.
We urge healthcare administrators to act now:
- Assess your hospital’s performance in patient experience and readmissions
- Develop targeted improvement strategies
- Engage with high-performing hospitals to share best practices.
Your efforts today can lead to higher star ratings tomorrow.
References
Centers for Medicare and Medicaid Services. (2024a). Hospital general information. https://data.cms.gov/provider-data/dataset/xubh-q36u
Centers for Medicare and Medicaid Services. (2024b). Statistical analysis system (SAS) package. https://qualitynet.cms.gov/inpatient/public-reporting/overall-ratings/sas
Kissam, S. M., Beil, H., Cousard, C., Greenwald, L. M., & Lloyd, J. T. (2019). States encouraging value-based payment: Lessons from CMS’s state innovation models initiative. The Milbank Quarterly, 97(2), 506-542. https://doi.org/10.1111/1468-0009.12380
Oddleifson, D. A., Xu, X., Ross, J. S., Spatz, E. S., & Desai, N. R. (2022). Assessment of market-level information on quality using hospital Care Compare. Journal of General Internal Medicine, 38(6), 1581-1583. https://doi.org/10.1007/s11606-022-07965-9
Trenaman, L., Harrison, M., & Hoch, J. S. (2024). What is a star worth to Medicare beneficiaries? A discrete choice experiment of hospital quality ratings. Health Affairs Scholar, 2(1), 1-7. https://doi.org/10.1093/haschl/qxad085
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