By Jordan Rau
American hospitals may have some of the most advanced medical technology in the world, but they hold an unimpressive record of ensuring their patients continue to get better after they leave. Roughly one in six Medicare patients ends up back in the hospital within a month, and researchers believe a third of those readmissions may be preventable.
The federal government publishes individual hospital readmission rates on its Hospital Compare website, and Medicare is in the fifth year of cutting payments to hospitals with high rates of rehospitalizations. Public scrutiny and financial hits from the penalties are prompting many hospitals to take steps to avert so many returns.
Readmission rates can be a reflection not only of the quality of a hospital but also the quality of the broader health care system in a community. You can do stories about:
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“Hot spotting” efforts to keep so-called “frequent flyer” patients out of the hospital.
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The particular health challenges facing low-income patients and the strategies employed by hospitals that treat them.
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Which hospitals are improving and which are not.
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How hospitals in your city, county, region or state compare to those in other places.
Nationally, readmissions have dropped in recent years, but they are still substantial: 22 percent of heart failure patients, for instance, return to the hospital within a month of discharge.
Readmission Rates
Individual hospital readmission rates can be viewed on Medicare’s Hospital Compare website or downloaded from data.medicare.gov in the Readmissions and Death – Hospital file. Medicare calculates a hospital-wide readmission rate as well as ones for seven conditions: heart attacks (AMI), lung disease (COPD), hip and knee replacement, heart failure (HF), pneumonia (PN), stroke (STK) and coronary artery bypass grafts. (CABG). There’s another file for state-level data and a third for national rates.
With these files, you will just see the outliers since Medicare rates nearly all hospitals as average unless it is statistically very likely that they are higher or lower than the national mean. In the most recent hospital-wide readmission rate reports, 4,073 hospitals rate no differently than the national rate, 283 are worse and 214 better.
Medicare’s hospital readmission reductions penalty program does not concern itself with such statistical niceties. More than half the nation’s hospitals are penalized this year. Starting with the federal fiscal year that began in October, 2,597 hospitals will have a year’s worth of Medicare payments reduced by up to 3 percent if they show high readmission rates. The best primer on how the penalty program measures readmissions is at QualityNet, particularly in the fact sheet and FAQs.
The penalties next federal fiscal year usually are announced each August. The most authoritative place to get individual hospital penalties is from the Impact Table from the Acute Inpatient Prospective Payment (IPPS) System Final Rule. (For the upcoming year, this is Impact Table from the Data Tables for Fiscal Year 2017.) The Readmissions Adjustment Factor is in Column BC. It is a little bit confusing because the lower the number, the higher the penalty. An adjustment factor of 1 means no penalty; an adjustment factor of 0.97 means the hospital gets only 97 percent of what it normally would get, or 3 percent less. The data is presented in a more user-friendly manner on data.Medicare.gov in the Hospital Readmissions Reduction Program file but, as I write this, hadn’t yet been updated. (An important tip to avoid a mistake: always use data from the latest fiscal year, and look at the files from the final rule, not the proposed rule.)
For fiscal 2017, Kaiser Health News has compiled the penalties for all five years of the program in a reader-friendly method in one spreadsheet you can use for free: it is in both csv and pdf formats. We subtract the adjustment factor from 1 and get a percentage penalty. Be cautious that changes in penalties over years of a fraction of a percent are not a big deal in reality to hospitals, even though they may look like the fine was doubled.
If you want to dig deeper and see which type of patients were readmitted at higher than expected rates, you can examine the Readmissions Reduction Supplemental Data File in the IPPS download section (here is Fiscal Year 2017). A hospital may claim its patients are sicker than most, but the government takes overall health into account when calculating readmission rates. Medicare does not, however, consider social and economic factors such as patients’ income levels or ability to follow instructions on how to care for themselves.
The government estimates the penalties for the 2017 fiscal year will total $528 million. The dollar figure for individual hospitals is very hard to get. CMS does not provide estimates. Some hospitals provide reporters with their figures, so it is worth asking.
Readmission Rates
To look at readmission rates and other hospital usage data on a local or regional level instead of by individual hospital, the Centers for Medicare & Medicaid Services offers a wealth of data by county, state and hospital referral region in its geographic variation public use files. These files contain 240 different data points, including readmission rates and raw numbers; emergency department visits, ambulance use, and what conditions are driving people to the hospital in the first place.
In 2014, Florida, Maryland, Michigan, New York, Rhode Island, West Virginia and the District of Columbia had readmission rates above 19 percent. The files also show that Mississippi has the highest rate of leg amputations for Medicare patients under 75 and the people under 40 are most likely to be admitted to the hospital for asthma in New Jersey and the District of Columbia. Hawaiian Medicare patients are the least likely to go to the emergency room.
Some consultant groups that can comment about how hospitals are dealing with readmissions are The Advisory Board Company, Avalere Health, and Premier. Industry perspective can come from the American Hospital Association, the Association of American Medical Colleges, or state hospital associations. Patient safety groups such as the Institute of Healthcare Improvement and the Leapfrog Group also can provide perspective.
Jordan Rau (@jordanrau)is a Senior Correspondent at Kaiser Health News, a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Reach him at jrau@kff.org.
