If Your 2024 Published Readmissions and Mortality Measures Are Lower than 2023, then 2025 Could Be Even Worse

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Hospital performance metrics for readmissions and mortality under CMS Quality Programs are critical for improving CMS Star Rating, VBP, HRRP, and other programs. These metrics are evaluated using data from a rolling three-year period, which shifts annually to include the most recent data while excluding the oldest.

Understanding the Rolling Period

The rolling three-year evaluation period for the CMS Quality Programs updates yearly:

This method involves adding the most recent year's data and dropping the oldest year's data from the evaluation period each year.

Impact of Performance Trends

The structure of the rolling period implies that two out of three years overlap between consecutive evaluations. Thus, poor performance in the newly added year (and the removal of better-performing older data) significantly influences future outcomes. These nuances are critical in understanding the impact of performance impact since the difference between the bottom 10th percentile and the top 90th percentile is very small.

To better illustrate the impact of the rolling period on the performance measurement of readmissions and mortality rates under CMS Quality Programs, a detailed table can help visualize the data included and excluded each year over a rolling three-year period. The following table includes both the numerators and denominators for each applicable year, as well as the specific readmission rates calculated from these values. The same logic would apply to mortality rates or any measure that has a rolling three-year period performance measure.

Detailed Table of CMS Quality Program Readmission Data

Performance Year Total Readmission Performance Period July 1, 2018 - June 30, 2019 July 1, 2019 - June 30, 2020 July 1, 2020 - June 30, 2021 July 1, 2021 - June 30, 2022 July 1, 2022 - June 30, 2023 Total Readmission Rates
2023 July 1, 2018 - June 30, 2021 10/200 (5%) 11/210 (5.24%) 13/220 (5.91%) Not Included Not Included 5.38%
2024 July 1, 2019 - June 30, 2022 Not Included 11/210 (5.24%) 13/220 (5.91%) 17/230 (7.4%) Not Included 6.18%
2025 July 1, 2020 - June 30, 2023 Not Included Not Included 13/220 (5.91%) 17/230 (7.4%) 14/240 (5.83%) 6.38%

Analysis of Readmission Rates Across Performance Years

The table above presents the data used to calculate the readmission rates for CMS Quality Programs over three consecutive performance years:

Implications for Hospitals

This analysis reveals the critical importance of monitoring and managing readmission and mortality rates each year. A single year of high readmissions or mortalities can adversely impact the calculated average readmission rates for multiple subsequent years due to the rolling nature of data evaluation in CMS Quality Programs. Hospitals must implement timely and effective strategies to improve or maintain their readmission rates, thus ensuring better performance evaluations in future years. This proactive approach is essential not only for meeting quality standards but also for enhancing patient care and outcomes.