In July of 2016, the Centers for Medicare & Medicaid Services (CMS) released a new Hospital Quality Star Rating system on the Hospital Compare website. Under this system, performance on a series of quality metrics is used to assign between one and five stars to a hospital, with a higher number of stars indicating better quality. Many rural hospitals do not have a CMS Hospital Quality Star Rating. Some of the reasons include challenging CMS data requirements, low volume (an insufficient number of hospital cases), or hospital decisions to not participate. The lack of a star rating can have two important consequences for rural hospitals. First, patients may perceive the lack of a star rating as a signal of lower quality of care and consequently avoid care at hospitals without a star rating (that is, they may misinterpret "no rating" as "zero stars").

CMS recently released its 2021 Hospital Quality Star Ratings, which incorporate several changes to the methodology. This change in methodology was intended to address methodological concerns about the 2016 Hospital Quality Star Ratings and to include more Critical Access Hospitals (CAHs) in the rating system. The purpose of this study is to 1) compare the 2021 CMS Hospital Quality Star Rating results for rural and urban hospitals, 2) to compare the 2021 and 2016 CMS Hospital Quality Star Rating results for rural hospitals, and 3) to identify implications for the usefulness of the CMS Hospital Quality Star Ratings for rural hospitals.

Key findings from this study include the following:

• Rural hospitals were more likely to be unrated than urban (41.6% vs. 12.0%).
• There was a large increase in the percentage of unrated rural hospitals between 2016 and 2021 (34.3% to 41.6%).
• Almost all (89.4%) unrated rural hospitals are CAHs.
• Almost half (45%) of unrated rural hospitals are in the Midwest census region.