Hospital
MADISON MEMORIAL HOSPITAL
CCN: 130025 · REXBURG, ID 83440 · MADISON County
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Middle
Top quartile
Percentile badges compare this hospital to all 5,426 hospitals nationally.
Overview
- Address
- 450 EAST MAIN STREET, REXBURG, ID 83440
- Phone
- (208) 359-6488
- Hospital Type
- Acute Care
- Ownership
- Government (Local)
- Emergency Services
- Yes
—
Star rating not available
Acute Care — General medical and surgical hospital participating in Medicare IPPS. Subject to CMS quality reporting and payment adjustment programs (VBP, HRRP, HAC).
CMS Star Rating — Quality Domain Breakdown
CMS computes the overall star rating from five quality domains. Each domain compares this hospital's measures against national benchmarks.
Mortality 1 of 7 measures reported
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 2 of 8 measures reported
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 4 of 11 measures reported
30-day unplanned readmission rates for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and CABG.
Patient Experience 8 of 8 measures reported
HCAHPS survey scores — patient-reported experience with communication, responsiveness, cleanliness, and discharge planning.
Timely & Effective Care 10 of 12 measures reported
Process-of-care measures including flu immunization, blood clot prevention, and appropriate use of imaging.
Readmissions — Hospital Readmissions Reduction Program
The Excess Readmission Ratio (ERR) compares this hospital's 30-day readmission rate to expected, adjusting for patient mix. An ERR of 1.0 means readmissions are as expected; > 1.0 triggers a Medicare payment penalty (up to 3%).
This hospital has excess readmissions in at least one condition and is subject to HRRP payment reduction.
Acute Myocardial Infarction (Heart Attack) 0 discharges
Heart Failure
Pneumonia
COPD
Hip/Knee Replacement
CABG Surgery
CMS Payment Programs
Three Medicare programs adjust hospital payments based on quality performance. Hospitals can be penalized under multiple programs simultaneously.
Readmissions (HRRP)
Penalized
Worst ERR: 1.0081
Value-Based Purchasing
—
HAC Reduction
No Reduction
HAC Score: -0.7806
Complications & Deaths
30-day mortality rates, patient safety indicators, and complication rates. "Better" means statistically significantly better than the national rate.
| Measure | Score | vs. National | Denominator |
|---|---|---|---|
| COMP_HIP_KNEE | — | Number of Cases Too Small | — |
| Hybrid_HWM | 4.30 | No Different Than the National Rate | 130 |
| MORT_30_AMI | — | — | — |
| MORT_30_CABG | — | — | — |
| MORT_30_COPD | — | Number of Cases Too Small | — |
| MORT_30_HF | — | Number of Cases Too Small | — |
| MORT_30_PN | 14.80 | No Different Than the National Rate | 30 |
| MORT_30_STK | — | Number of Cases Too Small | — |
| PSI_03 | 0.54 | No Different Than the National Rate | 312 |
| PSI_04 | — | Number of Cases Too Small | — |
| PSI_06 | 0.21 | No Different Than the National Rate | 377 |
| PSI_08 | 0.27 | No Different Than the National Rate | 372 |
| PSI_09 | 2.63 | No Different Than the National Rate | 121 |
| PSI_10 | 1.66 | No Different Than the National Rate | 56 |
| PSI_11 | 8.68 | No Different Than the National Rate | 54 |
| PSI_12 | 3.79 | No Different Than the National Rate | 128 |
| PSI_13 | 5.08 | No Different Than the National Rate | 40 |
| PSI_14 | 1.74 | No Different Than the National Rate | 35 |
| PSI_15 | 1.04 | No Different Than the National Rate | 79 |
| PSI_90 | 0.96 | No Different Than the National Value | — |
Patient Experience (HCAHPS)
Hospital Consumer Assessment of Healthcare Providers and Systems — standardized patient survey measuring satisfaction with care.
| Measure | Score | Star Rating |
|---|---|---|
| H_COMP_1_A_P: Nurses "always" communicated well | 75% | — |
| H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well | 4% | — |
| H_COMP_1_U_P: Nurses "usually" communicated well | 21% | — |
| H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score | — | — |
| H_COMP_1_STAR_RATING: Nurse communication - star rating | — | 3 |
| H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect | 84% | — |
| H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect | 2% | — |
| H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect | 14% | — |
| H_NURSE_LISTEN_A_P: Nurses "always" listened carefully | 72% | — |
| H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully | 6% | — |
| H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully | 22% | — |
| H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand | 68% | — |
| H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand | 4% | — |
| H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand | 28% | — |
| H_COMP_2_A_P: Doctors "always" communicated well | 81% | — |
| H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well | 4% | — |
| H_COMP_2_U_P: Doctors "usually" communicated well | 15% | — |
| H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score | — | — |
| H_COMP_2_STAR_RATING: Doctor communication - star rating | — | 4 |
| H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect | 88% | — |
| H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect | 2% | — |
| H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect | 10% | — |
| H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully | 79% | — |
| H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully | 5% | — |
| H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully | 16% | — |
| H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand | 75% | — |
| H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand | 5% | — |
| H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand | 20% | — |
| H_COMP_5_A_P: Staff "always" explained | 48% | — |
| H_COMP_5_SN_P: Staff "sometimes" or "never" explained | 24% | — |
| H_COMP_5_U_P: Staff "usually" explained | 28% | — |
| H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score | — | — |
| H_COMP_5_STAR_RATING: Communication about medicines - star rating | — | 2 |
| H_MED_FOR_A_P: Staff "always" explained new medications | 65% | — |
| H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications | 11% | — |
| H_MED_FOR_U_P: Staff "usually" explained new medications | 24% | — |
| H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects | 31% | — |
| H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects | 37% | — |
| H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects | 32% | — |
| H_COMP_6_N_P: No, staff "did not" give patients this information | 14% | — |
| H_COMP_6_Y_P: Yes, staff "did" give patients this information | 86% | — |
| H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score | — | — |
| H_COMP_6_STAR_RATING: Discharge information - star rating | — | 3 |
| H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge | 16% | — |
| H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge | 84% | — |
| H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms | 13% | — |
| H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms | 87% | — |
| H_CLEAN_HSP_A_P: Room was "always" clean | 73% | — |
| H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean | 8% | — |
| H_CLEAN_HSP_U_P: Room was "usually" clean | 19% | — |
| H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score | — | — |
| H_CLEAN_STAR_RATING: Cleanliness - star rating | — | 4 |
| H_QUIET_HSP_A_P: "Always" quiet at night | 55% | — |
| H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night | 10% | — |
| H_QUIET_HSP_U_P: "Usually" quiet at night | 35% | — |
| H_QUIET_LINEAR_SCORE: Quietness - linear mean score | — | — |
| H_QUIET_STAR_RATING: Quietness - star rating | — | 3 |
| H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) | 7% | — |
| H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) | 26% | — |
| H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) | 67% | — |
| H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score | — | — |
| H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating | — | 3 |
| H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) | 3% | — |
| H_RECMND_DY: "YES", patients would definitely recommend the hospital | 65% | — |
| H_RECMND_PY: "YES", patients would probably recommend the hospital | 32% | — |
| H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score | — | — |
| H_RECMND_STAR_RATING: Recommend hospital - star rating | — | 4 |
| H_STAR_RATING: Summary star rating | — | 3 |
Healthcare Associated Infections
Standardized Infection Ratios (SIR). A SIR < 1.0 means fewer infections than predicted based on national baseline data.
| Measure | Score (SIR) | vs. National |
|---|---|---|
| HAI_1_CILOWER | — | — |
| HAI_1_CIUPPER | — | — |
| HAI_1_DOPC | 357.000 | — |
| HAI_1_ELIGCASES | 0.230 | — |
| HAI_1_NUMERATOR | 1.000 | — |
| HAI_1_SIR | — | — |
| HAI_2_CILOWER | — | — |
| HAI_2_CIUPPER | — | — |
| HAI_2_DOPC | 1155.000 | — |
| HAI_2_ELIGCASES | 0.578 | — |
| HAI_2_NUMERATOR | 0.000 | — |
| HAI_2_SIR | — | — |
| HAI_3_CILOWER | — | — |
| HAI_3_CIUPPER | — | — |
| HAI_3_DOPC | 14.000 | — |
| HAI_3_ELIGCASES | 0.378 | — |
| HAI_3_NUMERATOR | 0.000 | — |
| HAI_3_SIR | — | — |
| HAI_4_CILOWER | — | — |
| HAI_4_CIUPPER | — | — |
| HAI_4_DOPC | 1.000 | — |
| HAI_4_ELIGCASES | 0.011 | — |
| HAI_4_NUMERATOR | 0.000 | — |
| HAI_4_SIR | — | — |
| HAI_5_CILOWER | — | — |
| HAI_5_CIUPPER | — | — |
| HAI_5_DOPC | 10609.000 | — |
| HAI_5_ELIGCASES | 0.264 | — |
| HAI_5_NUMERATOR | 0.000 | — |
| HAI_5_SIR | — | — |
| HAI_6_CILOWER | 0.015 | No Different than National Benchmark |
| HAI_6_CIUPPER | 1.461 | No Different than National Benchmark |
| HAI_6_DOPC | 7328.000 | No Different than National Benchmark |
| HAI_6_ELIGCASES | 3.375 | No Different than National Benchmark |
| HAI_6_NUMERATOR | 1.000 | No Different than National Benchmark |
| HAI_6_SIR | 0.296 | No Different than National Benchmark |
Timely & Effective Care
Process-of-care measures including ED wait times, treatment timeliness, and preventive care.
| Measure | Score | Condition |
|---|---|---|
| EDV | low | Emergency Department |
| GMCS | — | Electronic Clinical Quality Measure |
| GMCS_Malnutrition_Diagnosis_Documented | — | Electronic Clinical Quality Measure |
| GMCS_Malnutrition_Screening | — | Electronic Clinical Quality Measure |
| GMCS_Nutrition_Assessment | — | Electronic Clinical Quality Measure |
| GMCS_Nutritional_Care_Plan | — | Electronic Clinical Quality Measure |
| HH_HYPER | — | Electronic Clinical Quality Measure |
| HH_HYPO | 1.0 | Electronic Clinical Quality Measure |
| HH_ORAE | — | Electronic Clinical Quality Measure |
| IMM_3 | 65.0 | Healthcare Personnel Vaccination |
| OP_18a | 124.0 | Emergency Department |
| OP_18b | 120.0 | Emergency Department |
| OP_18c | 178.0 | Emergency Department |
| OP_18d | 185.0 | Emergency Department |
| OP_22 | 0.0 | Emergency Department |
| OP_23 | — | Emergency Department |
| OP_29 | 100.0 | Colonoscopy care |
| OP_31 | — | Cataract surgery outcome |
| OP_40 | — | Electronic Clinical Quality Measure |
| SAFE_USE_OF_OPIOIDS | 8.0 | Electronic Clinical Quality Measure |
| SEP_1 | 65.0 | Sepsis Care |
| SEP_SH_3HR | 100.0 | Sepsis Care |
| SEP_SH_6HR | — | Sepsis Care |
| SEV_SEP_3HR | 73.0 | Sepsis Care |
| SEV_SEP_6HR | 94.0 | Sepsis Care |
| STK_02 | — | Electronic Clinical Quality Measure |
| STK_03 | — | Electronic Clinical Quality Measure |
| STK_05 | — | Electronic Clinical Quality Measure |
| VTE_1 | 74.0 | Electronic Clinical Quality Measure |
| VTE_2 | 68.0 | Electronic Clinical Quality Measure |
Unplanned Hospital Visits
Readmission and ED return rates within 30 days of discharge.
| Measure | Score | vs. National |
|---|---|---|
| EDAC_30_AMI | — | — |
| EDAC_30_HF | 21.20 | Average Days per 100 Discharges |
| EDAC_30_PN | 16.90 | Average Days per 100 Discharges |
| Hybrid_HWR | 14.50 | No Different Than the National Rate |
| OP_32 | 13.30 | No Different Than the National Rate |
| OP_35_ADM | — | Number of Cases Too Small |
| OP_35_ED | — | Number of Cases Too Small |
| OP_36 | 1.10 | No Different than expected |
| READM_30_AMI | — | — |
| READM_30_CABG | — | — |
| READM_30_COPD | — | Number of Cases Too Small |
| READM_30_HF | 19.80 | No Different Than the National Rate |
| READM_30_HIP_KNEE | — | Number of Cases Too Small |
| READM_30_PN | 15.90 | No Different Than the National Rate |
Medicare Spending Per Beneficiary
MSPB ratio: values > 1.0 mean this hospital's episode spending is higher than the national median hospital.
Value
1.01
Financial Health (Cost Report — FY 2023)
All Data
Every labeled metric surfaced for this hospital, with national medians and percentiles where a benchmark is available.
Show 67 rows
| Source | Metric | Value | National Median | Pctl. | Raw key |
|---|---|---|---|---|---|
| Cost Report | Cost-to-Charge Ratio | 0.44 | — | metrics.cost_to_charge_ratio | |
| Cost Report | Current Ratio | 2.80 | — | metrics.current_ratio | |
| Cost Report | Employees per Bed | 10.10 | — | metrics.employees_per_bed | |
| Cost Report | fiscal_year | 2,023 | — | fiscal_year | |
| Cost Report | Fund Balance ($) | $91,147,099 | — | metrics.fund_balance | |
| Cost Report | Net Income ($) | $6,807,961 | — | metrics.net_income | |
| Cost Report | Net Patient Revenue ($) | $97,998,560 | — | metrics.net_patient_revenue | |
| Cost Report | Operating Margin (%) | 1.8% | — | metrics.operating_margin | |
| Cost Report | Total Assets ($) | $148,337,803 | — | metrics.total_assets | |
| Cost Report | Total Costs ($) | $80,739,247 | — | metrics.total_costs | |
| Cost Report | Total Liabilities ($) | $57,190,704 | — | metrics.total_liabilities | |
| Cost Report | Total Margin (%) | 6.6% | — | metrics.total_margin | |
| Cost Report | Uncompensated Care (%) | 2.6% | — | metrics.uncompensated_care_pct | |
| General Information | Address | 450 EAST MAIN STREET | — | Address | |
| General Information | City/Town | REXBURG | — | City/Town | |
| General Information | Count of Facility MORT Measures | 1 | — | Count of Facility MORT Measures | |
| General Information | Count of Facility Pt Exp Measures | 8 | — | Count of Facility Pt Exp Measures | |
| General Information | Count of Facility READM Measures | 4 | — | Count of Facility READM Measures | |
| General Information | Count of Facility Safety Measures | 2 | — | Count of Facility Safety Measures | |
| General Information | Count of Facility TE Measures | 10 | — | Count of Facility TE Measures | |
| General Information | Count of MORT Measures Better | 0 | — | Count of MORT Measures Better | |
| General Information | Count of MORT Measures No Different | 1 | — | Count of MORT Measures No Different | |
| General Information | Count of MORT Measures Worse | 0 | — | Count of MORT Measures Worse | |
| General Information | Count of READM Measures Better | 0 | — | Count of READM Measures Better | |
| General Information | Count of READM Measures No Different | 4 | — | Count of READM Measures No Different | |
| General Information | Count of READM Measures Worse | 0 | — | Count of READM Measures Worse | |
| General Information | Count of Safety Measures Better | 1 | — | Count of Safety Measures Better | |
| General Information | Count of Safety Measures No Different | 1 | — | Count of Safety Measures No Different | |
| General Information | Count of Safety Measures Worse | 0 | — | Count of Safety Measures Worse | |
| General Information | County/Parish | MADISON | — | County/Parish | |
| General Information | Emergency Services | Yes | — | Emergency Services | |
| General Information | Facility ID | 130025 | — | Facility ID | |
| General Information | Facility Name | MADISON MEMORIAL HOSPITAL | — | Facility Name | |
| General Information | Hospital overall rating | Not Available | — | Hospital overall rating | |
| General Information | Hospital overall rating footnote | 16 | — | Hospital overall rating footnote | |
| General Information | Hospital Ownership | Government - Local | — | Hospital Ownership | |
| General Information | Hospital Type | Acute Care Hospitals | — | Hospital Type | |
| General Information | Meets criteria for birthing friendly designation | — | — | Meets criteria for birthing friendly designation | |
| General Information | MORT Group Footnote | — | — | MORT Group Footnote | |
| General Information | MORT Group Measure Count | 7 | — | MORT Group Measure Count | |
| General Information | Pt Exp Group Footnote | — | — | Pt Exp Group Footnote | |
| General Information | Pt Exp Group Measure Count | 8 | — | Pt Exp Group Measure Count | |
| General Information | READM Group Footnote | — | — | READM Group Footnote | |
| General Information | READM Group Measure Count | 11 | — | READM Group Measure Count | |
| General Information | Safety Group Footnote | — | — | Safety Group Footnote | |
| General Information | Safety Group Measure Count | 8 | — | Safety Group Measure Count | |
| General Information | State | ID | — | State | |
| General Information | TE Group Footnote | — | — | TE Group Footnote | |
| General Information | TE Group Measure Count | 12 | — | TE Group Measure Count | |
| General Information | Telephone Number | (208) 359-6488 | — | Telephone Number | |
| General Information | ZIP Code | 83440 | — | ZIP Code | |
| HAC Reduction Program | fiscal_year | 2,026 | — | fiscal_year | |
| HAC Reduction Program | measures — cauti — sir | 0 | — | measures.cauti.sir | |
| HAC Reduction Program | measures — cdi — sir | 0.16 | — | measures.cdi.sir | |
| HAC Reduction Program | payment_reduction | No | — | payment_reduction | |
| HAC Reduction Program | total_hac_score | -0.78 | — | total_hac_score | |
| Medicare Spending per Beneficiary | End Date | 12/31/2024 | — | End Date | |
| Medicare Spending per Beneficiary | Measure ID | MSPB-1 | — | Measure ID | |
| Medicare Spending per Beneficiary | Start Date | 01/01/2024 | — | Start Date | |
| Medicare Spending per Beneficiary | Value | 1.01 | — | Value | |
| Readmissions (HRRP) | Acute Myocardial Infarction (Heart Attack) — Number of discharges | 0 | — | READM-30-AMI-HRRP.num_discharges | |
| Readmissions (HRRP) | Heart Failure — Excess readmission ratio | 1.01 | 0.9983 | p56 | READM-30-HF-HRRP.excess_readmission_ratio |
| Readmissions (HRRP) | Heart Failure — Expected readmission rate | 16.9% | — | READM-30-HF-HRRP.expected_readmission_rate | |
| Readmissions (HRRP) | Heart Failure — Predicted readmission rate | 17.1% | — | READM-30-HF-HRRP.predicted_readmission_rate | |
| Readmissions (HRRP) | Pneumonia — Excess readmission ratio | 0.99 | 0.9955 | p48 | READM-30-PN-HRRP.excess_readmission_ratio |
| Readmissions (HRRP) | Pneumonia — Expected readmission rate | 12.9% | — | READM-30-PN-HRRP.expected_readmission_rate | |
| Readmissions (HRRP) | Pneumonia — Predicted readmission rate | 12.9% | — | READM-30-PN-HRRP.predicted_readmission_rate |
Methodology
- Hospital General Information (dataset:
xubh-q36u, vintage: 2026, downloaded: 2026-04-13) - Hospital Readmissions Reduction Program (dataset:
hrrp, vintage: FY2026, downloaded: 2026-04-13) - Timely and Effective Care — Hospital (dataset:
hosp-timely-care, vintage: 2026, downloaded: 2026-04-13) - Complications and Deaths — Hospital (dataset:
hosp-complications, vintage: 2026, downloaded: 2026-04-13) - Patient Survey (HCAHPS) — Hospital (dataset:
hosp-hcahps, vintage: 2026, downloaded: 2026-04-13) - Healthcare Associated Infections — Hospital (dataset:
hosp-hai, vintage: 2026, downloaded: 2026-04-13) - Unplanned Hospital Visits — Hospital (dataset:
hosp-unplanned-visits, vintage: 2026, downloaded: 2026-04-13) - Medicare Spending Per Beneficiary — Hospital (dataset:
hosp-mspb, vintage: 2026, downloaded: 2026-04-13) - Hospital Provider Cost Report (dataset:
hosp-cost-report, vintage: 2023, downloaded: 2026-04-13) - Hospital-Acquired Condition (HAC) Reduction Program (dataset:
hac-reduction, vintage: FY2026, downloaded: 2026-04-13)