Q&A: Readmission metric

Q: We keep hearing about the readmission metric – what does this metric refer to? 

A: The readmission metric refers to patients discharged from an index hospital or the initial hospital admission and readmitted to any hospital in less than 30 days after the index hospital discharge. CMS is penalizing hospitals financially for as much as 3% less than the hospital’s allowed reimbursement if Medicare patients with certain diagnoses are readmitted to any hospital in less than 30 days; it is counted as an unnecessary readmission. CMS uses a national mean score as a benchmark score. The score changes monthly and is shared on the CMS Hospital Compare website. Population health models avoid unnecessary readmissions for all payer sources and diagnoses.   

Patients readmitted tend to experience a higher severity of illness at their index admission, are older, and have chronic conditions (Friedman, Jiang, & Elixhauser, 2008). With the advent of the ACA, hospitals face a 3% reduction in Medicare diagnosis-related group (DRG) prospective payments if they do not demonstrate an excess of patient readmissions. Heart failure, pneumonia, chronic obstructive lung disease, and myocardial infarctions are diagnoses targeted as those having a high proportion of unnecessary readmissions and are not fully reimbursable by CMS. The newer diagnoses added are myocardial infarction, coronary artery bypass grafts, and total joint replacement surgery. Many healthcare systems have plans in place to avoid all unnecessary readmissions despite the diagnosis (Moody-Williams, 2012). 

For more information, see Case Management Guide to Population Health: Management Across the Continuum of Care.

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