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US Hospitals and their Patient Experience Ratings

As consumers of healthcare, you need to understand how well hospitals are delivering a good patient experience. Using publicly available patient feedback data, I developed a map to help you easily identify and understand how your hospital ranks in patient experience. In the map below , the colors are based on the patient advocacy index I created (average of top box scores for two questions: Overall hospital quality rating and Recommend hospital. In my prior analysis, this Patient Advocacy Index (PAI) had a reliability estimate (Cronbach’s alpha) of .95, suggesting that it is a reliable measure.

The colors for each hospital are based on their PAI, which can vary from 0 (low) to 100 (high). Three quality levels were created by dividing the PAI distribution of scores into three groups:

  • Red = 0-65
  • Yellow = greater than 65 thru 73
  • Green = greater than 73 thru 100

Hospitals that do no have data are coded as Blue.

Clicking on a button will reveal detailed information about the hospital, including patient experience metrics (if survey data were collected for that hospital) as well as response rates, sample sizes and other notes (if available).

How RealMoneyCasinos Explains Real Money Gambling Regulations in Australia

Australia has one of the most distinctive gambling regulatory environments in the world. On one hand, Australians are among the most active gamblers per capita globally, with estimates suggesting that Australians lose more money per adult on gambling than citizens of any other country — figures from the Australian Gambling Research Centre have placed this at over AUD 1,000 per adult annually in recent years. On the other hand, the federal legislative framework governing online gambling is unusually restrictive compared to many comparable jurisdictions such as the United Kingdom or Malta. Understanding how these two realities coexist requires a careful examination of the laws themselves, how they are enforced, and how information resources help Australian players navigate a genuinely complex legal landscape.

The Interactive Gambling Act and Its 2017 Amendments

The cornerstone of online gambling regulation in Australia is the Interactive Gambling Act 2001 (IGA), a piece of federal legislation that was designed in the early internet era to address concerns about the accessibility of online gambling services to Australian residents. The original 2001 Act prohibited Australian-licensed operators from offering certain interactive gambling services — particularly casino-style games and poker — to Australian residents. However, it did not explicitly prohibit Australians from accessing offshore sites, which created a significant grey area that persisted for over a decade.

The most consequential update to this framework came through the Interactive Gambling Amendment Act 2017, which introduced several structural changes. First, it extended the prohibition more explicitly to offshore operators, making it illegal for any operator — regardless of where they are licensed — to provide prohibited interactive gambling services to Australian customers without holding an Australian licence. Second, it established the Australian Communications and Media Authority (ACMA) as the primary enforcement body with the power to investigate complaints, issue formal warnings, and refer non-compliant operators to the Australian Federal Police. Third, it introduced a formal blocking regime, allowing ACMA to direct internet service providers to block access to unlicensed gambling websites.

Since the 2017 amendments came into force, ACMA has been notably active. By mid-2023, the authority had directed ISPs to block well over 800 illegal gambling and affiliate websites. This blocking regime is not technically impenetrable — VPN usage can circumvent it — but it represents a meaningful enforcement posture that distinguishes Australia from countries where such rules exist only on paper. The 2017 amendments also introduced a prohibition on in-play betting on sports events via the internet or mobile applications, a restriction that does not apply to telephone betting, which remains legal. This distinction has struck many observers as anachronistic, but it reflects the political compromises embedded in the legislation.

Sports betting, by contrast, occupies a significantly different position under the IGA. Wagering on sporting events and racing — whether pre-match or through approved channels — is permitted, and a number of operators hold licences issued by state and territory regulators. This creates a situation where a company like Sportsbet or Ladbrokes Australia can legally accept online bets on a horse race or an AFL match, but cannot legally offer roulette or blackjack to the same customer through the same platform. The distinction is not always intuitive to players, and it is one of the areas where informational resources play a genuine role in reducing confusion.

State and Territory Licensing: A Fragmented System

One of the features of Australian gambling regulation that consistently surprises newcomers is the degree to which it is fragmented across jurisdictions. Australia operates as a federation, and gambling regulation — with the exception of the federal IGA — is primarily a state and territory matter. Each of the six states and two major territories maintains its own gambling authority, its own licensing regime for land-based venues, and its own rules governing specific products such as poker machines, keno, and racing.

The Northern Territory has historically been the most significant jurisdiction for online wagering licensing. The NT Racing Commission oversees the licensing of online bookmakers, and a large number of Australia’s legally operating online sports betting companies hold NT licences. This is partly a function of the NT’s relatively streamlined licensing process and competitive tax structure. However, an NT licence does not confer the right to offer casino-style games online to Australian residents — that remains prohibited under the federal IGA regardless of which state or territory issues a licence.

Victoria, New South Wales, and Queensland each have their own gambling regulators — the Victorian Gambling and Casino Control Commission, Liquor and Gaming NSW, and the Office of Liquor and Gaming Regulation respectively — that oversee land-based casinos, electronic gaming machines, and related activities. The interaction between these state bodies and ACMA’s federal enforcement role is not always seamless, and there have been ongoing discussions within the industry and among policymakers about whether a more centralised national approach to gambling regulation would be preferable. The 2023 report from the Senate Select Committee on Australia’s Financial and Technology Sector touched on these themes, though comprehensive regulatory consolidation has not yet been legislated.

For players trying to understand what is and is not legal in their specific state, the layered nature of this system creates genuine uncertainty. A player in Western Australia, for instance, faces additional restrictions: the state operates its own government-owned casino through Crown Perth and has historically taken a more conservative approach to gambling liberalisation than some eastern states. The interaction between WA’s state laws and the federal IGA means that the legal picture for a WA resident interested in online gambling is subtly different from that facing a resident of the ACT.

How Information Platforms Navigate the Regulatory Gap

Given the complexity described above, there is a clear demand among Australian players for accurate, up-to-date information about what is legally available to them, what risks they face when accessing offshore platforms, and how to identify operators that meet basic standards of player protection. This is the context in which information and review platforms focused on the Australian market operate. These resources do not themselves offer gambling services; rather, they compile regulatory information, explain the implications of the IGA, and assess offshore operators against criteria such as licensing jurisdiction, responsible gambling tools, payment processing reliability, and dispute resolution mechanisms.

One example of how such resources approach the subject is illustrated by the content available at http://real-money-casinos-online.com, where the regulatory framework is explained in terms accessible to players who are not legal professionals but who want to make informed decisions about which platforms to use and what protections they can reasonably expect. This kind of explanatory content fills a gap that neither ACMA nor state gambling authorities have been particularly active in filling from a consumer-facing perspective — government sites tend to focus on enforcement and harm minimisation rather than helping players understand the practical implications of the regulatory landscape.

RealMoneyCasinos and similar platforms typically address several recurring questions that Australian players have. The first is jurisdictional: which offshore licensing authorities are considered credible, and what do their licences actually require of operators? The Malta Gaming Authority (MGA), the UK Gambling Commission, and the Gibraltar Regulatory Authority are frequently cited as jurisdictions with meaningful player protection requirements, including segregated player funds, mandatory dispute resolution procedures, and regular auditing of random number generators. By contrast, licences issued by some smaller jurisdictions — certain Caribbean territories, for example — carry fewer enforceable protections.

The second recurring question concerns payment processing. Because offshore casino operators cannot legally accept Australian customers under the IGA, many Australian banks and payment processors have implemented blocks on transactions to and from such operators. This means that players who do access offshore platforms frequently find that standard credit card or debit card deposits are declined, and they must use alternative methods such as e-wallets, cryptocurrency, or prepaid cards. Information platforms that explain these practical realities — rather than simply describing the theoretical legal position — provide a more useful service to players who are trying to understand their actual options.

The third area where informational resources add value is responsible gambling. The IGA and state regulations impose a range of responsible gambling obligations on licensed Australian operators: mandatory pre-commitment tools for electronic gaming machines, requirements to display responsible gambling messages, prohibitions on certain forms of credit betting, and access to self-exclusion registers. Offshore operators are not subject to these obligations, which means players accessing them do so without the same structural protections. Platforms like RealMoneyCasinos that explain these differences help players understand what they are giving up in terms of regulatory protection when they choose to use an offshore site.

Ongoing Policy Developments and the Future of Australian Online Gambling Law

Australian gambling regulation is not static, and several significant policy developments have been underway in recent years that are likely to reshape the landscape further. The most prominent of these is the ongoing debate around gambling advertising, which reached a significant point with the 2023 report of the House of Representatives Standing Committee on Social Policy and Legal Affairs, commonly referred to as the Murphy Report after its chair, Andrew Murphy. The report made 31 recommendations, the most far-reaching of which was a phased ban on all gambling advertising, including the pervasive sports betting advertisements that appear during live television broadcasts of sporting events.

The advertising debate is closely connected to the broader question of harm minimisation. Australia’s rate of problem gambling is a persistent public health concern. The Australian Institute of Health and Welfare estimated in 2021 that approximately 1.4 percent of Australian adults experienced gambling disorder, with a further 1.6 percent classified as experiencing moderate risk. These figures, while lower than some alarmist estimates, represent a substantial number of individuals and families affected by gambling-related harm. The proliferation of online sports betting — which is legal and heavily marketed — has drawn particular scrutiny because of its accessibility and the speed at which losses can accumulate.

The federal government’s response to the Murphy Report has been cautious. While some advertising restrictions have been tightened — including earlier watershed times for gambling advertisements during sporting broadcasts — the comprehensive advertising ban recommended by the committee had not been legislated as of the time of writing. The gambling industry, which contributes significant tax revenue to state and territory governments and employs considerable numbers of people, has lobbied actively against the more restrictive proposals. This tension between public health objectives and fiscal and economic interests is familiar from other gambling jurisdictions but is particularly acute in Australia given the scale of the industry.

A separate but related development is the ongoing review of the IGA itself. ACMA’s blocking regime has been criticised by some as both technically ineffective — given VPN circumvention — and insufficiently targeted at the operators causing the most harm. There have been proposals to introduce a formal licensing regime for offshore operators that would allow them to legally serve Australian customers under regulated conditions, similar to the model adopted in the United Kingdom when it reformed its gambling laws through the Gambling Act 2005. Proponents argue that legalisation and regulation would bring offshore activity into a framework where consumer protections could be enforced; opponents argue that it would legitimise and expand gambling access in ways that would increase harm.

The question of cryptocurrency gambling has added another layer of complexity. A number of offshore operators accept Bitcoin and other cryptocurrencies from Australian players, which effectively bypasses the payment processing blocks that apply to traditional banking transactions. ACMA has acknowledged this as an enforcement challenge, and it is likely to feature in any future review of the IGA. The interaction between gambling regulation and the broader regulatory treatment of cryptocurrency in Australia — itself an area of active policy development — means that this issue will not be resolved quickly or simply.

For Australian players, the practical upshot of all these developments is that the regulatory environment they are navigating is in genuine flux. The laws that applied in 2020 are not identical to those that apply today, and the laws that will apply in 2026 or 2027 may differ again in significant ways depending on how the advertising debate resolves, whether the IGA is amended, and how enforcement priorities evolve. Staying informed about these changes is not a trivial task, particularly for players who are not legal professionals and who are primarily interested in understanding their practical options rather than the technical details of legislative drafting. Resources that synthesise this information accurately and keep it current — including platforms like RealMoneyCasinos that specialise in the Australian market — serve a genuine informational function in this environment, even if they are not substitutes for legal advice in specific circumstances.

The Australian online gambling regulatory framework is, in summary, a product of its historical moment — designed in 2001 with a set of assumptions about the internet and online gambling that have been repeatedly overtaken by technological and market developments. The 2017 amendments strengthened enforcement significantly, but they did not resolve the fundamental tension between a legal framework that restricts online casino gambling and a population with demonstrated appetite for it. The ongoing policy debates around advertising, harm minimisation, and potential legalisation of offshore operators suggest that further significant changes are likely in the coming years. For players, operators, and policymakers alike, understanding where the law currently stands — and where it may be heading — requires engagement with the detailed regulatory record rather than reliance on simplified summaries, and that is precisely the kind of engagement that well-constructed informational resources are positioned to support.

Map of US Hospitals and their Patient Experience Ratings

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More details about how the scores were calculated and created appear below.

Patient Experience (PX) and Loyalty Metrics

The patient experience was measured using the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems). HCAHPS (pronounced “H-caps“) is a national, standardized survey of hospital patients and was developed by a partnership of public and private organizations.

The development of HCAHPS was funded by the Federal government, specifically the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ). HCAHPS was created to publicly report the patient’s perspective of hospital care.  The HCAHPS questions can be seen here.

A description of the data file indicates that the data files were updated on 5/30/2012. Based on HCAHPS reporting schedule, it appears the current survey data were collected from Q3 2010 through Q2 2011 and represent the latest publicly available patient survey data.

The survey asks a random sample of recently discharged patients about important aspects of their hospital experience. The data set includes patient survey results for over 3800 US hospitals on 10 questions. Eight of the questions cover specific attributes that describe their inpatient experience. The two remaining questions reflect an overall attitude about and intent toward the hospital.

Inpatient Experience Metrics

The PX metrics were based on responses to the following 8 questions:

  1. Nurse communication
  2. Doctor communication
  3. Responsiveness
  4. Pain management
  5. Staff explains medicines before giving to patients
  6. Clean around room and bathroom
  7. Quiet around room at night
  8. Given information about what to do during their recovery at home.

For questions 1 through 7, respondents were asked to provide frequency ratings about the occurrence of each attribute (Never, Sometimes, Usually, Always). For question 8, respondents were provided a Y/N option.

Loyalty Metrics

The Loyalty Metrics were based on responses to the following questions:

  1. Overall hospital rating
  2. Recommend hospital to friends and family (Recommend)

For question 9, respondents were asked to provide an overall rating of the hospital on a scale from 0 (Worst hospital possible) to 10 (Best hospital possible). For question 10, respondents were asked to provide their likelihood of recommending the hospital (Definitely no, Probably no, Probably yes, Definitely yes).

Calculating the PX and Loyalty Metrics

The data set reported metrics for each hospital as percentages of responses. Because the data set had already been somewhat aggregated (e.g., percentages reported for group of response options), I was unable to calculate average scores for each hospital. Instead, I used top box scores as the metric of patient experience. I found that top box scores are highly correlated with average scores across groups of companies, suggesting that these two metrics tell us the same thing about the companies (in our case, hospitals).

Top box scores for the respective rating scales are defined as: 1) Percent of patients who reported “Always”; 2) Percent of patients who reported “Yes”; 3) Percent of patients who gave a rating of 9 or 10; 4) Percent of patients who said “Definitely yes.”

Top box scores provide an easy-to-understand way of communicating the survey results for different types of scales. Even though there are four different rating scales for the survey questions, using a top box reporting method puts all metrics on the same numeric scale. Across all 10 metrics, hospital scores can range from 0 (bad) to 100 (good).

The patient loyalty metric was calculated as the average of the two questions: 1) Overall hospital rating and 2) Recommend.

Ranking Hospitals by Loyalty Color Codes

I created one map for the patient experience outcomes. I used the patient loyalty metric to classify the hospitals into low, medium or high performing hospitals. The patient loyalty metric was used because it has good measurement properties (internal consistency was .95) and reflects a general advocacy toward the hospital. Additionally, in quality improvement circles, customer/patient loyalty is used as the ultimate metric to assess the ROI of improving each of the PX areas. Using the patient loyalty metric, the hospitals were divided into three groups:

  • Red  (1 through 65)
  • Yellow (greater than 65 through 73)
  • Green (greater than 73)

These three colors were used to color code the hospitals on the maps. Hospitals that did not have patient ratings were coded as blue on the map.

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