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Type:
Hosp Inpt eCQMs - Hospital Inpatient eCQMs
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Resolution: Answered
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Priority:
Moderate
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Component/s: None
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None
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Nathan J Currah
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5303327384
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Enloe Health / Enloe Medical Center [050039]
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CMS1028v2
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Negatively skews our publicly reported performance data and potentially impacts our overall hospital star rating.
The October 2025 Hospital Care Compare report CMS just released for review and correction, under Maternal Health and Perinatal Care, lists our PC-07a rate as 395 per 10,000 patients for 1Q24-4Q24 (denominator of 1,948 patients). This rate seems extraordinarily high. Our PC-07 results from patient discharge data sent to CQMCC indicates a rate of only 257 (50 num cases / 1940 den cases x 10,000). And our PC-07 eCQM (data sent to HQR via QRDA1 files) shows a denominator population of 1902 and a numerator of 38 which results in only 200 per 10,000 patients. We know we have top-tier perinatal quality performance at our organization and are routinely recognized for it across multiple quality oversight organizations, so we opened a ticket with CMS asking for insights into how CMS is measuring the PC-07a rate as listed on the latest Care Compare report. We stated we would appreciate the opportunity to have our rate corrected before the October report is fully released. If the rate is correct as it stands, we would like to understand where opportunities for improvement are, so we can address those moving forward. CMS responded by stating that the results cannot be corrected and that our scores would not be published, and they closed the ticket. We reopped the ticket because we need clarification as to whether the results cannot be corrected because this is a CMS problem that potentially affects everyone, and if so, will they do they right thing for all organizations? Why does CMS say this cannot be corrected when we are in a preview and correction window until September 30th? What are we supposed to do before the next submission window? Does CMS think we reported our data incorrectly or did CMS calculate things incorrectly? Also, while we appreciate CMS not counting our PC-07 scores against us, it means that we cannot leverage our actual good scores in favor of boosting our overall star rating. What are other hospitals experiencing with their PC-07 scores on Care Compare?