Q&A: Understand readmission metrics

Q: What does the readmission 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 penalizes 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. The Affordable Care Act, targets heart failure, pneumonia, chronic obstructive lung disease, and myocardial infarctions as having a high proportion of unnecessary readmissions not fully reimbursable by CMS. Recently added diagnoses include 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. 

Editor’s note: This Q&A was originally answered in Revenue Cycle Advisor. For more information, see Case Management Guide to Population Health: Management Across the Continuum of Care.