HCAHPS Star Ratings Explained: How Hospitals Are Scored

By Jason Messerli, Strategic Advisor, Customer Strategy, NRC Health

Roughly 3,200 hospitals showed up on the January 2025 HCAHPS Star Ratings list. 

The top of the curve was thin, with only about 9% of all hospitals earning five stars. The group of one star hospitals was thinner still, around 3%. 

About 17% of hospitals sat in the two-star band. Everything else fell into the three- and four-star bands, and the boundary between those two was close enough that a small move in the national mean could push a hospital across it without much else changing. 

Most patient experience leaders I work with live in that middle band. Most of what’s useful to say about star ratings is about that band, too. 

That number, the HCAHPS star rating next to your hospital’s name on Care Compare, is is publicly available — to your CFO, a competitor’s marketing team, a prospective hire, or a parent deciding where to deliver a baby. Whether or not they look, it also feeds the formula behind CMS’s 2% Medicare DRG withhold, the dollars that flow back to your operating budget every year through Hospital Value-Based Purchasing (VBP). 

Most of that part isn’t news to anyone running patient experience. The piece I find more useful, and that I want to walk through here, is the mechanics CMS uses to turn a 32-question survey into one whole-number star, and what to do when your star moves and your patients’ scores haven’t. 

Understanding the public star is one thing. Understanding what’s driving it is another. Learn how NRC Health’s CAHPS solutions help hospitals connect survey results to operational improvement efforts across the patient experience journey. 

Key takeaways:  

• A hospital can improve internally and still lose an HCAHPS Star Rating if national performance improves faster. 
• The Summary Star oversimplifies patient experience performance. Experienced Patient Experience (PX) leaders focus more on long-term trends, underlying measure movement, and operational consistency than on a quarterly refresh. 
• Survey methodology changes in 2025–2026, including new web/email collection modes and redesigned measures, are reshaping how hospitals should interpret HCAHPS performance trends. 
• Care coordination is becoming one of the strongest drivers of PX performance, alongside nurse and physician communication. 
• HCAHPS Star Ratings affect more than reputation. They influence Medicare reimbursement, competitive positioning, and how patients, staff, and leadership perceive a hospital. 

An HCAHPS Star Rating is a 1-to-5 score CMS publishes quarterly on Hospital Care Compare for each acute-care hospital that collects at least 100 completed HCAHPS surveys over four consecutive quarters. The rating is calculated from patient responses to the standardized HCAHPS survey, adjusted for survey mode and patient mix, then assigned a whole-number star from 1 (lowest) to 5 (highest) using a clustering algorithm that places hospitals into five performance categories based on the most current national distribution. 

That’s the textbook. Now, the parts the textbook leaves out.

The HCAHPS Star Rating measures PX only. It comes from the HCAHPS survey, refreshes every quarter, and shows up as eight individual measure stars plus one Summary Star on each hospital’s Care Compare page. 

The Overall Hospital Quality Star Rating is the broader one, annual instead of quarterly, and built from a wider basket of measures. PX is one piece. The additional components  are mortality, readmissions, safety of care, and the timely-and-effective-care domain. The 2026 release landed May 13, and it’s the first refresh to pull OAS CAHPS into the PX side of the calculation, which means hospital outpatient departments will finally factor in. 

When the C-suite asks about “our star rating,” I always ask which one they mean. They aren’t the same number; they don’t refresh at the same cadence; and a strong HCAHPS Star Rating doesn’t guarantee a strong Overall Hospital Quality Star Rating.

Three things move when a new quarterly refresh hits Care Compare. 

1. Reimbursement 

The first is reimbursement. Every IPPS hospital has 2% of its base operating DRG payments withheld each fiscal year, and CMS redistributes that pot back through Hospital VBP based on a Total Performance Score. The Person and Community Engagement domain, which is built directly from your HCAHPS scores, accounts for a quarter of that total. 

The mechanics inside that domain are worth knowing because they reward both performance and trajectory. 

CMS sets two thresholds for each measure: an achievement threshold pegged to the national 50th percentile, and a benchmark threshold pegged to the average of the top decile. 

Score above the benchmark, and you max out achievement points. Score between the two, and you collect something. 

Below the achievement threshold, you can still earn improvement points by beating your own baseline from two years prior, and CMS uses whichever number, achievement or improvement, is higher. For a 300-bed hospital, the difference between earning some of those points and earning none can be the difference between a budget conversation that goes well and one that doesn’t.

2. Reputation

Reputation is the second piece. Your stars sit on the front page of your Care Compare profile. So do your competitors’ stars. 

When a patient is comparing two hospitals, both ratings are right there in the same view. About a third of US hospitals were rated three stars in the January 2025 ratings  r. Another third of US Hospitals were at four. Five-star hospitals accounted for 9% of the field; one-star hospitals, 2%. Most hospitals are bunched into the two middle groups, and the space between them is small. Chances are that is where your local competitor is sitting.

3. Operational

Operationally, the Summary Star usually becomes the number everyone talks about because it’s faster than unpacking eight separate measures and CMS methodology every quarter. Not many people outside of PX teams are spending time on the underlying measures or adjustment methodology. They see the star rating and react to that first. 

The challenge is that the Summary Star doesn’t accurately reflect the day-to-day work teams do at the bedside. That’s partly because of how the methodology rolls multiple measures together and recalculates performance against the national distribution each quarter. 

Step 1: Eligible Patients Complete the 32-Question Survey 

The redesigned HCAHPS survey took effect for patients discharged on or after January 1, 2025. It contains 32 questions: 22 ask how often or whether something happened during the stay, 3 are screeners that route patients to the right follow-ups, and 7 collect the demographic and self-reported health information CMS uses to adjust scores across hospitals. 

CMS also sets a minimum survey threshold for public HCAHPS Star Ratings. Hospitals need at least 100 completed surveys over a four-quarter reporting period. Below that, Care Compare may still publish the raw measure scores, but the public star ratings are no longer displayed. 

One critical-access hospital I work with spends a lot of time watching survey volume because they’re usually sitting near the cutoff. They can end up a few surveys short without anything being fundamentally wrong operationally. 

When that happens, their Care Compare profile doesn’t show a lower star rating. It shows no star rating at all. For smaller hospitals, especially, the 100-survey requirement becomes something teams pay attention to year-round. 

Step 2: Responses Get Converted to Linear Mean Scores 

Inside each frequency-style question, think “how often did the nurses listen carefully to you” — CMS converts responses to a 0-to-100 score. Never is 0. Sometimes is 33⅓. Usually it is 66⅔. Always is 100. Those numbers average up into a linear mean for the measure. 

This can be confusing to those working on PX day in and day out primarily because CMS reports top-box scores on Care Compare.  In fact, most internal dashboards lead with the top-box (the percentage of patients who said “Always”) because the top-box is easier to communicate to nursing units and service-line leaders. In top-box scoring, essentially no credit is given for any answers outside of the most positive response.  That is not the case for star ratings.  The linear mean is what CMS uses to calculate your star, and it’s more sensitive to movement in the middle of the distribution. 

This trips up people who work in PX day in and day out, and the reason is CMS uses two different scoring methods for two different jobs. The scores you see by domain on Care Compare and the numbers most internal dashboards lead with are top-box scores. Top-box scores are the percentage of patients who chose the most positive response, “Always.” Top-box is the right tool for that job. It’s easy to communicate to nursing units and service-line leaders, and it points straight at the gap between “Usually” and “Always,” which is where most improvement work actually happens. 

Star ratings are built differently. CMS doesn’t use top-box to calculate the star. It uses the linear mean, which gives partial credit across the full range of responses instead of counting only the top answer. That’s why the linear mean is more sensitive to movement in the middle of the distribution: a shift from “Sometimes” to “Usually” moves the linear mean even though it never touches top-box. 

The takeaway isn’t to start managing to the linear mean. Top-box is still the better day-to-day metric for improvement, and it’s what your frontline teams should keep seeing. The point is just to understand that the star rides on a different calculation than the score on your dashboard so the two can drift apart without either one being wrong. 

Step 3: CMS Adjusts for Survey Mode and Patient Mix 

CMS adjusts HCAHPS scores in two ways before publicly comparing hospitals. 

The first is survey mode adjustment. Put simply, patients don’t respond to surveys the same way across all formats. Response patterns shift depending on whether the survey was mailed, conducted over the phone, sent by email, or used a mixed-mode approach. CMS applies statistical adjustments so hospitals using different collection methods can still be compared within the same national dataset. 

The 2025 changes added the redesigned HCAHPS survey along with newer web/email collection methods. So, if a hospital recently changed survey modes, some score movement may be tied to that rather than a change in PX patient experience. 

There’s another issue underneath that which is easier to miss.  

I covered this in a recent CAHPS Insider Live session. Nationally, roughly 63% of HCAHPS respondents are 65 or older but in several 2025 system reviews, I saw that figure reach 75% or even 80% at individual organizations.The important part wasn’t just the percentage itself. Some of those same organizations had been much closer to the national average only a few years earlier. 

Their patient populations didn’t suddenly age that dramatically in a short period. The survey response pool changed. In many cases, the collection method influenced who actually responded. 

That’s worth paying attention to because a stable score doesn’t necessarily mean the underlying sample remains representative of the broader patient population. 

In addition to mode adjustments, CMS also adjusts for the mix of patients that a given hospital serves. Patient-mix adjustments (PMA) have been debated since the inception of HCAHPS.    

Research has shown that certain patient characteristics influence how patients tend to respond to experience-style questions, regardless of the care they received. Younger and more educated patients tend to rate hospitals more negatively, for example. 

CMS factors in a range of demographic and self-reported health variables when adjusting HCAHPS scores. These include but are not limited to age, education, service line, overall health status, mental health status, home language, and ER admission. 

There are also several things CMS does not adjust for in the patient-mix methodology. The model doesn’t account for clinical severity or DRG weighting. It also doesn’t factor in staffing levels, payer mix, or broader socioeconomic conditions in the surrounding community. 

Critics have pointed out for years that this can create disadvantages for some safety-net hospitals in particular. But from a reporting standpoint, PMA is still the comparison framework CMS relies on. 

Step 4: A Clustering Algorithm Groups Hospitals Into Five Categories 

After adjustment, every hospital’s scores get grouped using a statistical clustering algorithm. It’s the same algorithm CMS uses for Medicare Advantage and Part D star ratings. The method identifies natural gaps in the national distribution and builds five categories in and builds five categories so that hospitals in the same group score as similarly as possible, while the groups themselves are as different from one another as possible.  

Two parts of the methodology tend to catch people off guard. One is that CMS only reports whole-number stars, so there is no middle ground between a three-star and four-star hospital publicly. 

The other is that the scoring thresholds move. CMS recalculates them each quarter based on current national performance. So a hospital can improve its raw scores and still see the public star rating stay flat or even decline if the rest of the field improved faster during the same reporting period. 

That’s usually what’s behind the inquisitive calls that happen after a quarterly refresh. Internally, teams feel like performance improved because, in many cases, it did. However, the comparison group moved too. 

Step 5: Eight Measure Stars and One Summary Star (for Now) 

Care Compare currently displays eight individual HCAHPS measure stars plus the HCAHPS Summary Star Rating. As we covered in the February 2026 CAHPS Insider, the Care Transitions and Responsiveness of Hospital Staff composites are not currently displayed during the transition to the redesigned survey. 

The October 2026 Care Compare refresh is expected to be the first to display all 11 measures from the updated survey, 8 unchanged carryovers, plus 3 new measures from the redesigned questionnaire. The eight measures you see today are a snapshot of a moving methodology. 

The Summary Star is calculated by averaging your eight measure stars and then re-clustering that average against the field. A strong four on five measures and a weak two on three measures rarely averages out the way teams expect. 

CMS updates HCAHPS Star Ratings every quarter using rolling discharge data. The April 2026 refresh, for example, is based on patients discharged between July 1, 2024, and June 30, 2025. 

Here’s the rough sequence of changes CMS rolled out across 2025 and into 2026: 

• January 1, 2025. Redesigned HCAHPS survey took effect for new discharges. Web and email modes were formally added. 
• January 2026 Care Compare refresh. First refresh built primarily on legacy survey data, with the transition underway. Eight measure stars displayed. 
• April 2026 Care Compare refresh. Reflected discharges from July 1, 2024, through June 30, 2025. Patient-mix adjustments and national means for this period were posted on February 19, 2026. 
• May 13, 2026. 2026 Overall Hospital Quality Star Ratings were published, with OAS CAHPS measures incorporated into the Patient Experience domain for the first time. 
• October 2026 Care Compare refresh. Three new HCAHPS measures are expected to enter public reporting, expanding the displayed domainsfrom 8 to 11. 

If you’re benchmarking against your own historical stars right now, draw a clear line between pre-transition and post-transition periods. Some movement during this window reflects which measures are being scored, not how care is being delivered.

In my experience, this is the most useful piece of the processto internalize. 

Three forces drive the kind of star movement that doesn’t match what your team is feeling on the floor: 

• The clustering is relative. With 36% of hospitals at three stars and 32% at four, the boundary between those two groups is doing a lot of work, and doing it on small score differences. A modest improvement in the national mean can pull the cut-point across your linear mean. 
• The HCAHPS transition is still underway. Different measures are being phased into the public star calculations at different points between 2025 and 2026, which makes this reporting window harder to compare with prior years. 
• Hospital size plays a role. Research shows smaller hospitals tend to see larger swings in certain HCAHPS measures… 

particularly in discharge and nurse communication, because smaller response pools are more sensitive to changes in survey volume. 

That means quarterly star movement at a 150-bed hospital may look a lot less level than it does at a large academic medical center working with a much larger response pool. 

1. Read Four Quarters Before You Read One

A single quarterly refresh doesn’t tell you much on its own, especially for hospitals close to the 100-survey cutoff. One reporting period can look very different from the next simply because the response pool changed. 

Longer trends are more useful. Looking across multiple quarters makes it easier to tell the difference between a short-term fluctuation and a pattern that’s actually developing over time.

2. Build a Peer Comparison Group That Looks Like You

National averages can be helpful for context, but they only tell you so much. A regional community hospital and a large academic medical center rarely serve the same patient population, have the same service mix, or exhibit the same admission patterns. 

The more useful comparison is a narrower one: hospitals that look operationally similar to yours. Similar geography, similar payer mix, similar patient flow, similar types of admissions. Those are the organizations that tend to give you a better read on where your HCAHPS performance stands quarter to quarter.

3. Spend Your Improvement Budget on the Underlying Measures

The Summary Star is a lagging, aggregated indicator. Improvement occurs at the underlying measure level, and post-2025, the leverage map has changed. 

For most of the past decade, communication with nurses and communication with doctors have been the highest-correlated drivers of overall hospital rating. They still matter. But care coordination, which became a mandated domain in the redesigned survey, is now competing for that spot. 

Across my 2025 partner reviews, roughly 90% of hospitals had at least one care-coordination metric showing up as a top-three correlate. That isn’t a finding about the survey. It’s a finding about what patients have always cared about and now finally have a way to tell us.A lot of care coordination happens off-stage. Patients can’t rate what they can’t see. 

That’s why visibility is important. In some organizations, the opportunity isn’t necessarily doing more coordination work. It’s making the coordination patients are already benefiting from easier to recognize during their stay. 

Aligned messaging at the bedside is part of this. Nothing loses trust faster than a doctor saying one thing and a nurse saying another. 

Another pitfall to avoid is trying to focus on every domain at once. I’ve watched organizations stand up improvement committees for all eight measures simultaneously, and the result is almost always the same. 

You spread a thin layer of effort across the whole survey, and nothing moves. Pick one focus, maybe two, that are highly correlated measures and stay there for at least two quarters before you reassess. At that point, think about tweaks/fine-tuning rather than wholesale changes to focus areas. Too often improvement efforts fail because they are abandoned before they become second nature. 

How Is the HCAHPS Summary Star Rating Calculated? 

CMS calculates the Summary Star Rating by averaging a hospital’s eight individual HCAHPS measure stars (for the current 2026 reporting periods) and then applying a clustering algorithm to that average to assign a final whole-number rating from 1 to 5. 

How Often Does CMS Update HCAHPS Star Ratings? 

CMS refreshes HCAHPS Star Ratings quarterly. Each refresh uses four quarters of patient discharge data, with the exact reporting period spelled out in the technical notes for that release. 

How Many HCAHPS Surveys Does a Hospital Need Before CMS Publishes Star Ratings? 

CMS requires a minimum of 100 completed HCAHPS surveys over four quarters before a hospital receives public star ratings. Hospitals below that threshold may still have scores visible on Care Compare, but the stars themselves don’t appear. 

Why Would an HCAHPS Star Rating Change If Our Scores Stayed About the Same? 

One reason is that the scoring thresholds are recalculated each quarter against national performance trends. HCAHPS Star Ratings are relative to how hospitals are performing overall during that reporting period, not just to a fixed internal benchmark. 

Because of that, a hospital can see consistent, or even slightly improved, scores, while the public star rating still changes as the national distribution shifts. 

Does CMS Adjust HCAHPS Star Ratings for Patient Acuity or Case Complexity? 

CMS applies patient-mix adjustments to account for certain demographic and self-reported health factors, including age, education, service line, overall health rating, mental health rating, and preferred language spoken at home. 

At the same time, several operational and socioeconomic factors remain outside the adjustment model. HCAHPS methodology does not currently adjust for DRG severity, payer mix, staffing levels, or broader community socioeconomic conditions. 

How Is an HCAHPS Star Rating Different From the Overall Hospital Quality Star Rating? 

The two ratings measure different things and update on different schedules. 

HCAHPS Star Ratings focus specifically on PXe and are refreshed quarterly through Care Compare. 

Overall Hospital Quality Star Rating combines multiple quality domains, including mortality, readmissions, patient safety, effective care, and PX. This rating is updated annually. 

The 2026 Overall Hospital Quality Star Rating release also introduces OAS CAHPS measures into the Patient Experience portion of the calculation for the first time.

A public HCAHPS Star Rating can look deceptively simple. One number. One to five stars. Easy to compare at a glance. 

The work underneath it is not simple. 

The methodology changes. The thresholds move. Survey modes influence who responds. Smaller hospitals deal with very different reporting dynamics than larger systems. Sometimes the public rating shifts before frontline teams feel much difference at all inside the organization. 

That’s part of why PX leaders have to look past the Summary Star itself. 

The hospitals that tend to improve over time are usually the ones that pay attention to longer-term patterns rather than reacting to one quarterly refresh. They watch individual measures. They monitor response distribution, not just top-box scores. They focus on operational consistency at the bedside long before they focus on public reporting optics. 

Because in the end, while Star Ratings provide a succinct, public facing summary of Hospital Performance, they fall exceedingly short in   conveying how patients actually felt during their stay.