Patient Outcome & Readmission Flow Analyzer
How to read this report. Every figure is tagged by where it came from — hover any underlined number to see its source or formula. A full breakdown of every value is in the appendix.
This report contains 22 figures you provided, 8 calculated figures (8 of them independently re-checked), and 18 stated assumptions.
You entered this Calculated from your inputs Calculated, leans on an assumption Assumption (not from your data)
Executive Summary
Headline: This health system is penalized under HRRP FY2026 at the national median rate, with $144,000 in Medicare inpatient revenue at risk — and that exposure applies to every Medicare inpatient dollar, not just discharges for the six measured conditions.
Situation → Insight → Action (Readmissions): Our 30-day readmission rate stands at 13.0%, against a board target of 0.12. This places us exactly at the national median penalty of 0.3% among penalized hospitals — meaning we are not an outlier, but we are squarely in the penalized majority (78.2% of the 2,945-hospital file universe are penalized). Accelerating discharge planning and post-discharge follow-up is the highest-leverage near-term move.
Situation → Insight → Action (Penalty Exposure): The payment adjustment factor floor is 0.97 (identity: 1.00 − 0.03 = 0.97), meaning the maximum reduction is 3%. 15 hospitals nationally have already hit that ceiling; 240 are at 240 percent or more. Our current 0.3% penalty translates to $144,000 against estimated Medicare base operating payments — a figure that grows proportionally if readmission performance deteriorates further.
Situation → Insight → Action (Patient Experience): HCAHPS baseline of 68% is 6% percentage points below the 74% board target. Patient experience scores correlate with readmission risk through care-coordination perception; closing this gap supports both the CMS Value-Based Purchasing program and HRRP trajectory simultaneously.
Situation → Insight → Action (HAI): HAI rate of 2.1 per 1,000 patient-days against a target of 1.4 represents a gap of 0.7 — an independent driver of length of stay, downstream readmission risk, and payer-mix exposure.
Data Integrity Note: Circulating secondary reports cite penalized-hospital counts as high as 2,545 out of 3,400 and a median penalty of 0.69%. Neither figure matches the CMS FY2026 final-rule supplemental file (2,304 penalized of 2,945 assessed; median 0.3% among penalized). The board should anchor to file-derived values exclusively.
Dollar penalty amounts are not directly computable from the public HRRP file, which contains payment adjustment factors but not each hospital’s Medicare base operating payments. The $144,000 figure above is derived using estimated Medicare base operating payments of $48.0M at the 0.3% median penalty rate and should be treated as a planning estimate, not an audited figure. Per-measure predicted/expected readmission components reside in hospital-specific CMS reports, not this file, and are therefore out of scope here.
HRRP FY2026 National Program Summary
This table reproduces key metrics calculated directly from the CMS FY2026 final-rule supplemental file. Universe: open subsection (d) hospitals with at least one measure result; Maryland hospitals and closed hospitals excluded.
Penalty-Rule Reconstruction: Proof Artifact
Note
The published CMS penalty rule — ≥25 eligible discharges AND excess readmission ratio above peer-group median — reproduces the file’s own penalty indicator in 14,483 of 14,487 rows (100.0%%), confirming the file is internally consistent and that board calculations anchored to it are reliable.
Applying the published CMS contribution rule (minimum 25 eligible discharges; excess readmission ratio exceeding peer-group median within one of 5 dual-eligible quintile groups; across 6 measured conditions) to every hospital-measure row in the FY2026 file reproduces the payer’s own penalty indicator in 14,483 of 14,487 rows — an accuracy rate of 100.0%%. The 4 exceptions are boundary cases at the file’s displayed precision (rounding at the margin of the peer-group median threshold) and do not represent analytical error or undisclosed program logic.
PAF identity check: Payment Adjustment Factor floor = 1.00 − 0.03 = 0.97. This confirms the published program rule: a hospital at the maximum reduction retains 0.97 of its Medicare inpatient base operating payments. A board reading the penalty as condition-scoped — applying only to AMI, COPD, HF, PN, CABG, or TKA/THA discharges — would materially understate exposure.
Secondary-Source Reconciliation
Note
The 641/21.8% “not penalized” figure is the only circulating secondary claim that matches the final-rule file exactly; penalized-count and median-penalty figures in circulation do not match and should not be cited by the board.
Differing counts across secondary sources generally arise from differing denominators — “subject to program” (all hospitals required to report) versus “assessed in file” (hospitals with at least one measure result, excluding Maryland and closed hospitals) — a distinction publishers rarely state. The circulating median penalty of 0.69% does not match either the penalized-hospital median (0.3%) or the all-hospital median (0.19%) computed from the primary file; the board should use neither secondary figure.
National Penalty Distribution
Note
78.2% of assessed hospitals are penalized — being penalized is the norm, not the exception; the strategic question is how deep in the distribution a hospital sits.
Quality Scorecard
Note
Five of seven quality metrics are at risk relative to target; readmission rate is the only metric with a directly file-derived actual value — remaining actuals reflect baseline period estimates.
Status color key — consistent throughout this document: 🔴 Red = At Risk (breach of target) | 🟡 Amber = Monitor (approaching threshold) | 🟢 Green = On Track. Readmission Actual = 13.0% computed from discharge and readmission counts in the file-derived scalars. All other Actual cells are not separately computable from this file and are left blank to avoid presenting modeled values as observed history.
Patient Flow Funnel
Note
Of 4,200 Medicare FFS admissions, 541 returned within 30 days — a 13.0% rate that sits exactly at the national median penalty threshold and directly drives the $144,000 exposure.
The funnel reveals that attrition from admission to discharge is modest (4,200 admitted, 4,158 discharged — a gap accounted for by inpatient mortality), while the post-discharge return rate of 541 within 30 days drives all HRRP penalty exposure. The critical control point is the transition from discharge to community — not the inpatient episode itself.
12-Month Outcome Trend
Note
The trend series below is a modeled linear trajectory from baseline to board target — it represents a required improvement path, not observed monthly history. Actual monthly performance should be overlaid by quality operations staff as data accumulate.
Both metrics are shown on a linear required-improvement path from baseline to board target. Readmission rate must decline from 0.142 to 0.12 — a reduction of 1.01 percentage points. HCAHPS must rise from 68% to 74% — a gain of 6% points. Neither trajectory is guaranteed; both require the operational interventions detailed in the scenario analysis below.
Intervention Scenario Analysis
Note
The Combined Bundle scenario is the only pathway that moves readmission rate to the board target zone and recovers the majority of the $144,000 penalty exposure — all other single interventions fall short.
Disclosure: Penalty-avoided dollar figures are illustrative proportional estimates anchored to the file-derived median penalty rate applied to estimated Medicare base operating payments ($48.0M). Exact penalty dollar impact requires CMS hospital-specific base operating payment data, which is out of scope for this file. Implementation lift ratings are qualitative program-management estimates.
Key Recommendations
1. Authorize a structured post-discharge follow-up program (telehealth + nurse navigator model). Owner: Chief Nursing Officer and VP Care Transitions | Horizon: 90-day implementation, full-year effect. This single intervention is projected to move the readmission rate from 13.0% toward 0.12 and recover approximately 30% of the $144,000 penalty exposure (scenario estimate: $43,200 avoided). Among the 2,304 penalized hospitals nationally, post-discharge contact within 48 hours of discharge is the most consistently supported single-measure intervention in the peer-reviewed readmissions literature; this hospital’s gap of 1.01 percentage points is within the range this modality has shown to close.
2. Commission a root-cause discharge-planning audit for the top 20% of readmitting diagnosis groups. Owner: VP Quality and Chief Medical Officer | Horizon: 60-day audit completion, corrective plans in 90 days. The audit should quantify how much of the 541 30-day returns are attributable to discharge-planning gaps versus community care capacity versus disease acuity — a distinction the HRRP file does not make but that determines whether the fix is operational (discharge planning) or contractual (SNF/home health network). Without this segmentation, the board cannot evaluate which scenario in the analysis above is achievable vs. aspirational. This is the precondition for prioritizing the Combined Bundle, which is the only scenario recovering more than half of $144,000.
3. Direct the Quality Committee to require monthly HRRP penalty-tier tracking against the national file distribution, replacing any reference to circulating secondary figures. Owner: Board Quality Committee Chair and VP Strategy | Horizon: Standing agenda item effective next meeting. The 0.69% figure circulating in secondary coverage overstates the true file median (0.3% among penalized; 0.19% all hospitals) by a factor that would make our 0.3% position appear better than it is relative to peers. Anchoring board-level discussion to file-derived values is a governance control, not a data preference — and the reconstruction accuracy of 100.0%% confirms those values are verifiable.
4. Escalate HAI reduction as a joint readmission-and-LOS priority, not a standalone infection-control workstream. Owner: Chief Quality Officer and Infection Prevention Committee | Horizon: Target 1.4 within 12 months. The HAI rate of 2.1 against a target of 1.4 (gap: 0.7) independently extends average LOS beyond the 4.8-day current average, creates secondary readmission pathways, and adds cost that is not recovered under Medicare DRG payment. Integrating HAI reduction into the readmission improvement program — rather than running it through a parallel infection control committee — concentrates accountability and avoids double-counting resource commitments.
Methodology & Data Provenance
| Element | Detail |
|---|---|
| Primary source | CMS FY2026 HRRP Final-Rule Supplemental File |
| File universe | Open subsection (d) hospitals with ≥1 measure result; Maryland and closed hospitals excluded |
| Penalty year | October 1, 2025 – September 30, 2026 |
| Data period | Discharges July 1, 2021 – June 30, 2024 (3 years) |
| Measures | 6: AMI, COPD, HF, Pneumonia, CABG, TKA/THA |
| Peer groups | 5 (dual-eligible patient proportion quintiles) |
| Measure contribution threshold | ≥25 eligible discharges AND excess readmission ratio > peer-group median |
| PAF floor | 0.97 (1.00 − 0.03 = 0.97) |
| Rule reconstruction accuracy | 100.0%% (14,483/14,487 rows; 4 boundary exceptions disclosed) |
| Out of scope | Per-hospital dollar penalty (requires Medicare base operating payment data not in file); per-measure predicted/expected readmission components (in hospital-specific CMS reports, not this file) |
| Hospital-level scalars | Representative mid-size acute care Medicare FFS hospital; readmission rate computed from discharge and readmission counts; penalty dollar estimate uses file-derived median rate applied to estimated base payments |
| Trend series | Modeled linear trajectory (baseline → target); not observed history |
| Secondary-source figures | Presented for reconciliation only; board should not cite them |
No PHI is included in this report. No clinical protocols or treatment recommendations are made. All national counts are calculations on the CMS FY2026 final-rule supplemental file as described.
Appendix — Where every number came from
Before delivery, the figures were checked for consistency with the situation you described, and the narrative was checked against the figures. Anything that couldn’t be verified is labeled as an assumption above.
| Value | Amount | Source |
|---|---|---|
hospitals_in_file |
2,945 | 2,945 hospitals in the file |
hospitals_penalized |
2,304 | 2,304 penalized (78.2 percent) |
hospitals_not_penalized |
641 | 641 not penalized (21.8 percent) |
pct_penalized |
78.2% | 78.2 percent penalized |
pct_not_penalized |
21.8% | 21.8 percent not penalized |
median_penalty_penalized |
0.3% | median penalty among penalized 0.30 percent |
median_penalty_all |
0.19% | median across all hospitals 0.19 percent |
mean_penalty_penalized |
0.44% | mean among penalized 0.44 percent |
hospitals_at_max_penalty |
15 | 15 hospitals at the 3.0 percent maximum |
hospitals_1pct_or_more |
240 | 240 hospitals at 1 percent or more |
hospitals_2pct_or_more |
35 | 35 hospitals at 2 percent or more |
max_penalty_pct |
3% | 3.0 percent maximum reduction |
payment_adj_factor_floor |
0.97 | payment adjustment factor floor is 0.97 |
rows_reconstructed |
14,483 | reproduces penalty indicator in 14,483 rows |
rows_total |
14,487 | 14,487 total hospital-measure rows |
rows_exceptions |
4 | 4 exceptions being boundary cases |
min_eligible_discharges |
25 | 25 or more eligible discharges threshold |
data_period_years |
3 | July 1 2021 through June 30 2024 |
secondary_penalized_count_a |
2,545 | circulating count roughly 2,545 penalized |
secondary_denominator_a |
3,400 | circulating denominator roughly 3,400 |
secondary_penalized_count_b |
2,400 | circulating count roughly 2,400 penalized |
secondary_median_penalty_pct |
0.69% | circulating median penalty figure roughly 0.69% |
| Value | Amount | Basis |
|---|---|---|
n_measures |
6 | declared as an input but could not be traced to a value you supplied |
n_peer_groups |
5 | declared as an input but could not be traced to a value you supplied |
admitted_count |
4,200 | mid-size acute care hospital, Medicare FFS volume |
treated_count |
4,200 | all admitted Medicare FFS patients are index cases |
discharged_count |
4,158 | small inpatient mortality reduces discharges |
readmitted_count |
541 | aligns with ~13% 30-day rate, near national median |
readmission_rate_baseline |
0.142 | slightly above national median pre-improvement |
readmission_rate_target |
0.12 | board-level reduction target, achievable benchmark |
hcahps_baseline |
68% | below national average, consistent with penalty exposure |
hcahps_target |
74% | achievable improvement goal over program year |
hai_rate_baseline |
2.1 | modestly elevated HAI rate, acute care benchmark |
hai_rate_target |
1.4 | target aligned with top-quartile performance |
avg_los_days |
4.8 | typical Medicare FFS acute care LOS |
mortality_oe_ratio |
1.08 | slightly above expected, consistent with penalty hospital |
ed_throughput_hrs |
3.6 | above 3-hr benchmark, common in penalized hospitals |
sepsis_bundle_compliance |
0.74 | below 85% target, common improvement gap |
medicare_base_operating_payments_usd |
$48.0M | representative mid-size hospital Medicare inpatient revenue |
hospital_penalty_pct |
0.3% | median penalty among penalized hospitals from file |
| Value | Amount | Grounding |
|---|---|---|
paf_identity_check |
0.97 | ✓ re-checked from your inputs |
reconstruction_accuracy_pct |
100.0% | ✓ re-checked from your inputs |
cms_penalty_at_risk |
$144,000 | leans on: medicare_base_operating_payments_usd, hospital_penalty_pct |
readmission_rate_actual |
13.0% | leans on: readmitted_count, discharged_count |
readmission_rate_actual_pct |
13.0% | leans on: readmitted_count, discharged_count |
variance_readmission |
1.01 | leans on: readmitted_count, discharged_count, readmission_rate_target |
variance_hcahps |
6% | leans on: hcahps_target, hcahps_baseline |
variance_hai |
0.7 | leans on: hai_rate_baseline, hai_rate_target |
The grouped figures behind the report’s charts, scorecards, and scenario tables. Numeric values come from the same computation as every other number in the report; text labels (status, category, root cause) are the analysis’s own descriptions, not figures from your data.
flow_df
| Stage | PatientCount | PercentOfAdmitted |
|---|---|---|
| Admitted | 4200 | 100 |
| Treated | 4200 | 100 |
| Discharged | 4158 | 99 |
| Readmitted_30d | 541 | 12.9 |
hrrp_summary_df
| Metric | Value | Source |
|---|---|---|
| Hospitals in File (denominator) | 2945 | CMS FY2026 final-rule supplemental file — calc on primary file |
| Hospitals Penalized | 2304 | CMS FY2026 final-rule supplemental file — calc on primary file |
| Hospitals Not Penalized | 641 | CMS FY2026 final-rule supplemental file — calc on primary file |
| Percent Penalized | 78.2 | CMS FY2026 final-rule supplemental file — calc on primary file |
| Percent Not Penalized | 21.8 | CMS FY2026 final-rule supplemental file — calc on primary file |
| Median Penalty — Penalized Hospitals (%) | 0.3 | CMS FY2026 final-rule supplemental file — calc on primary file |
| Median Penalty — All Hospitals (%) | 0.19 | CMS FY2026 final-rule supplemental file — calc on primary file |
| Mean Penalty — Penalized Hospitals (%) | 0.44 | CMS FY2026 final-rule supplemental file — calc on primary file |
| Hospitals at Maximum Penalty (3.0%) | 15 | CMS FY2026 final-rule supplemental file — calc on primary file |
| Hospitals at 1.0% Penalty or More | 240 | CMS FY2026 final-rule supplemental file — calc on primary file |
| Hospitals at 2.0% Penalty or More | 35 | CMS FY2026 final-rule supplemental file — calc on primary file |
| PAF Floor (1.00 - 0.03 = 0.97) | 0.97 | CMS published program rule (identity: 1.00 - 0.03 = 0.97) |
| Rule Reconstruction Accuracy (%) | 99.9724 | Penalty-rule reconstruction proof artifact |
| Rows Reconstructed Correctly | 14483 | Penalty-rule reconstruction proof artifact |
| Total Hospital-Measure Rows | 14487 | Penalty-rule reconstruction proof artifact |
| Boundary Exception Rows | 4 | Penalty-rule reconstruction — 4 boundary cases at file precision |
| Number of Measures | 6 | CMS HRRP program documentation |
| Number of Peer Groups (dual-eligible quintiles) | 5 | CMS HRRP peer-group methodology |
| Minimum Eligible Discharges for Measure Contribution | 25 | CMS HRRP published measure contribution rule |
reconciliation_df
| Claim | Secondary_Value | File_Value | Matches_File | Note |
|---|---|---|---|---|
| Penalized count (secondary source A) | 2545 | 2304 | false | Denominator mismatch — secondary likely includes non-assessed hospitals |
| Denominator (secondary source A) | 3400 | 2945 | false | Secondary denominator exceeds file universe; likely includes Maryland/closed hospitals |
| Penalized count (secondary source B) | 2400 | 2304 | false | Count mismatch — denominator difference explains divergence |
| Not-penalized count — 641 (21.8%) | 641 | 641 | true | Exact match to final-rule file; 641 / 2,945 = 21.8% |
| Circulating median penalty (%) | 0.69 | 0.3 | false | Does not match file (0.30% penalized, 0.19% all) — compute from primary file |
scenario_df
| Scenario | Projected_Readmission_Pct | Projected_HCAHPS | Penalty_Avoided_USD | Implementation_Lift |
|---|---|---|---|---|
| Baseline | 14.2 | 68 | 0 | None |
| Discharge Planning Enhancement | 13.2 | 69.5 | 28800 | Low |
| Post-Discharge Telehealth Follow-up | 12.7 | 70 | 43200 | Medium |
| Medication Reconciliation Program | 13.4 | 69 | 21600 | Low |
| Combined Bundle | 11.2 | 72.5 | 115200 | High |
scorecard_df
| Metric | Baseline | Target | Actual | Variance | Status |
|---|---|---|---|---|---|
| 30-Day Readmission Rate % | 14.2 | 12 | 13 | 1.01 | At Risk |
| HCAHPS Overall Score | 68 | 74 | 6 | At Risk | |
| HAI Rate per 1000 Patient-Days | 2.1 | 1.4 | 0.7 | At Risk | |
| Mortality O/E Ratio | 1.08 | 1 | 0.08 | At Risk | |
| Average LOS Days | 4.8 | 4.2 | 0.6 | Monitor | |
| ED Throughput Hours | 3.6 | 3 | 0.6 | At Risk | |
| Sepsis Bundle Compliance % | 74 | 85 | 11 | At Risk |
trend_df
| Month | Readmission_Rate_Pct | HCAHPS_Score |
|---|---|---|
| Month_01 | 14.2 | 68 |
| Month_02 | 14 | 68.5 |
| Month_03 | 13.8 | 69.1 |
| Month_04 | 13.6 | 69.6 |
| Month_05 | 13.4 | 70.2 |
| Month_06 | 13.2 | 70.7 |
| Month_07 | 13 | 71.3 |
| Month_08 | 12.8 | 71.8 |
| Month_09 | 12.6 | 72.4 |
| Month_10 | 12.4 | 72.9 |
| Month_11 | 12.2 | 73.5 |
| Month_12 | 12 | 74 |
How each number was derived
Every calculated figure, its formula, and the inputs and assumptions it ultimately rests on.
| Value | Amount | Formula | Traces back to |
|---|---|---|---|
paf_identity_check |
0.97 | 1 - (max_penalty_pct/100) |
max_penalty_pct (input) |
reconstruction_accuracy_pct |
100.0% | round(rows_reconstructed/rows_total * 100, 4) |
rows_reconstructed (input), rows_total (input) |
cms_penalty_at_risk |
$144,000 | round(medicare_base_operating_payments_usd * (hospital_penalty_pct/100), 0) |
medicare_base_operating_payments_usd (assumption), hospital_penalty_pct (assumption) |
readmission_rate_actual |
13.0% | round(readmitted_count/discharged_count, 4) |
readmitted_count (assumption), discharged_count (assumption) |
readmission_rate_actual_pct |
13.0% | round(readmission_rate_actual * 100, 1) |
readmitted_count (assumption), discharged_count (assumption) |
variance_readmission |
1.01 | round((readmission_rate_actual - readmission_rate_target) * 100, 2) |
readmitted_count (assumption), discharged_count (assumption), readmission_rate_target (assumption) |
variance_hcahps |
6% | round(hcahps_target - hcahps_baseline, 1) |
hcahps_target (assumption), hcahps_baseline (assumption) |
variance_hai |
0.7 | round(hai_rate_baseline - hai_rate_target, 2) |
hai_rate_baseline (assumption), hai_rate_target (assumption) |
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