The article outlines eight challenges faced by CMOs, CNOs, and Quality Teams in managing hospital Quality Programs. Hospitals often grapple with unpredicted program score changes due to complex scoring mechanisms. Moreover, they struggle to pinpoint improvement strategies from myriad possible measures, find it hard to set and track progress towards goals, and remain uncertain about intervention efficacy. Additionally, the lack of access to out-of-hospital data, the rapidly changing nature of program measures, a slim margin for error in data approximations, and the inability to invest in advanced quality improvement technologies further complicate their endeavors to enhance care quality.

Quality and safety measures have long been at the forefront of healthcare, ensuring that hospitals provide optimal care to their patients. Two significant entities, The Leapfrog Group and the Centers for Medicare & Medicaid Services (CMS), have instituted multiple programs to monitor and assess these measures. Though these programs have several overlapping measures, hospitals often tackle them individually, leading to potential inefficiencies. Dexur's innovative approach, using AI simulations and calculators, offers a consolidated strategy for hospitals to improve upon these common measures.

Every day, hospitals and healthcare systems grapple with hundreds of quality measures that impact critical quality programs like CMS Star Rating, VBP, HRRP, and Leapfrog. These measures, encompassing everything from mortality and readmission rates to HCAHPS Patient experience measures, are pivotal in determining patient care strategies, upholding hospital reputation, and clinching significant financial incentives.

CMS Mortality measures are a critical part of CMS Star Ratings (~22% of overall weightage) and VBP (~25% of Weightage). Within the CMS Mortality measures, Pneumonia, HF, AMI and COPD are the most common measures in Mortality. A big gap while Hospitals try to measure 30 Day mortality is that Hospitals are blind to what happens outside their walls and nearly 60% of deaths are outside the Index Stay. Since, Dexur is an approved purchaser of Medicare Claims data, we can provide insights into what happens out of the Index stay and how what percentage of patient deaths can be potentially impacted.

The Hospital CMS Star Ratings, designed to measure the quality of healthcare institutions, often presents hospitals with the challenging task of comprehending its intricate methodologies, encompassing performance periods, time lags, and specific weightages of different measures. Dexur, recognizing the complexity of these ratings, has identified that a significant portion of their interactions with hospitals revolves around elucidating these aspects. The need for clarity becomes particularly pronounced when considering that various teams within hospitals - from top-tier executives like the CEO, COO, CMO, CQO, and CNO to the Quality Departments - often have divergent understandings of how the Star Ratings function.

Dexur’s 2024 Star Rating August 2023 Guidance is now available for hospitals and healthcare providers to review. Dexur has a 98% accuracy rate for its predictions in February. Our guidances, based on partial data, are less accurate but are still very useful to understand directionality, strengths, weaknesses and opportunities. Dexur customers may have a different guidance than what is shared below because they may have provided additional data to use in our guidance model.

In the vast expanse of the healthcare landscape, where patient care and hospital reputation are inextricably linked, hospitals frequently deploy a myriad of quality improvement initiatives, interventions, and actions. The goal is clear: to enhance the quality of care and ensure that patients receive the best possible treatment outcomes. However, there’s an underlining challenge that Chief Medical Officers (CMOs), Chief Nursing Officers (CNOs), and Quality Teams often grapple with — How do we know if these interventions are genuinely working?

Hospitals face challenges in tracking CMS (Centers for Medicare & Medicaid Services) 30-Day readmissions due to the limitations of data. The 30-day Readmission measure is calculated based on the number of patients who are readmitted within 30 days of their initial hospital admission. However, hospitals lack access to comprehensive out-of-hospital information, making it difficult for them to track these measures accurately. Dexur is an approved purchaser of Medicare claims data and which allows it to evaluate patient outcomes, identify patterns and trends, and provide a more complete picture of healthcare utilization and performance. This data can be instrumental in identifying areas for improvement, developing strategies to reduce mortality and readmissions, optimizing resource allocation, and enhancing the overall quality of care.

CMS just released its 2023 CMS Star Ratings on July 26, 2023. Based on the data files, released Dexur compared its CMS Star Rating predictions made in Jan / Feb 2023 to actual CMS published files and the details of comparison are shown below.

The key stats are given below:

1. Dexur made a prediction on 2926 Hospitals

2. Dexur correctly forecasted the CMS Star Rating in 2874 Hospitals (Green Highlighted in below table)

3. Therefore, Dexur has a 98% (2874/2926) predictive accuracy for 2023 CMS Star Ratings

4. 52 Hospitals (Highlighted in pink in the below table) were incorrectly forecasted

Hospitals have a challenge in tracking CMS 30-Day Mortality measures because they try to monitor more real-time information using internal hospital data, which does not have out-of-hospital information used for 30-day mortality and readmission measures. However, Dexur is an approved purchaser of Medicare claims data and, therefore, can analyze the full patient journey that impacts measures such as 30-day mortality, 30-day readmissions, MSPB, and EDAC.

CMS QAPI (Centers for Medicare & Medicaid Services Quality Assurance and Performance Improvement) encourages healthcare organizations to establish and monitor quality improvement goals. These goals can align with the metrics and measures used in CMS quality programs, including Star Ratings, VBP and HRRP. By setting specific goals to improve performance on quality measures that impact Star Ratings VBP and HRRP, healthcare organizations can directly link their compliance efforts to the desired outcomes in CMS quality programs.

In the pursuit of improving healthcare quality and patient outcomes, the Centers for Medicare & Medicaid Services (CMS) rely on various measures to evaluate the performance of hospitals and healthcare providers. Two crucial indicators that have garnered significant attention to assess hospital performance are readmission and mortality rates. These measures are crucial in measuring Hospitals’ performance in various CMS quality programs. For instance, readmissions and mortality measures constitute 44% weightage in the calculation of CMS Star Ratings, and readmissions are the sole driver of the Hospital Readmissions Reduction Program (HRRP).