Unlocking the Mystery: Exploring the Differences in Readmission Penalties for the Dual-Eligible

Dual-eligible readmission penalties differ from other readmission penalties by taking into account the proportion of patients a hospital serves who are dually eligible for Medicare and Medicaid, essentially penalizing hospitals less severely if they have a higher percentage of these complex, often high-needs patients, as dual eligibility is considered a marker of significant social risk factors that can contribute to higher readmission rates; this adjustment helps to mitigate penalties for hospitals serving populations with greater social needs. Key Points About Dual-Eligible Readmission Penalties Social risk stratification: The main difference is that dual-eligible penalties incorporate "peer grouping" where hospitals are compared to others with similar proportions of dual-eligible patients, reducing penalties for hospitals with a high percentage of dual-eligible patients compared to hospitals with a lower percentage. Reduced penalty potential: Hospitals with a higher proportion of dual-eligible patients may face lower penalties compared to hospitals with a lower proportion, even if their overall readmission rate is similar. Policy goal: The goal of this stratification is to acknowledge that dual-eligible patients often have complex medical needs and social determinants of health that can contribute to higher readmission rates, preventing undue penalties for hospitals serving these populations. The average penalty for hospitals with the highest proportion of Medicare-Medicaid dual-eligible patients is lower than the average penalty for hospitals with the lowest number of dual-eligible patients. Highest average penalty: 0.31% Lowest average penalty: 0.32% Dual-Eligible Readmission Penalties and Social Determinants Readmission penalties for hospitals that serve a higher proportion of dual-eligible patients are often reduced, compared to hospitals serving fewer dual-eligible patients. This is because of social risk adjustment and peer grouping, which are methods used to reduce penalties for hospitals that serve socially disadvantaged patients. Social risk adjustment: Socioeconomic status and race are included in the calculation of readmission penalties. This can lead to a reduction in penalties for both safety net and non-safety net hospitals. Peer grouping: Hospitals are grouped together based on the proportion of dual-eligible patients they serve. Hospitals with a higher proportion of dual-eligible patients are often given reduced penalties. 3 Key Findings Related to Dual-Eligibility and Readmission Penalties 1. Dual-eligible beneficiaries have higher 30-day readmission rates than Medicare-only beneficiaries. However, the difference varies by the type of hospital stay and the location of the patient. For example: Teaching hospitals are more likely to receive a reduced penalty. Large hospitals are more likely to receive a reduced penalty. Not-for-profit hospitals are less likely to receive a penalty reduction than for-profit hospitals. Hospitals in the Midwest and South are less likely to receive a penalty reduction than hospitals in the Northeast. 2. Type of hospital stay based on medical conditions For AMI, HF, and pneumonia, dual-eligible patients had higher 30-day readmission rates than non-dual-eligible patients in 99.0%, 99.4%, and 97.5% of US hospitals, respectively. 3. Readmission rates Overall, those who qualified as dually eligible had a readmission rate of 19.4% versus 12.3% for beneficiaries who did not. The readmission rate was higher among dually eligible beneficiaries 18–64 years than for those in this age group without dual-eligibility (21.5% versus 15.3%, respectively). Hospitals and home care agencies can partner to reduce hospital readmissions for dual-eligible beneficiaries through programs that improve care transitions, coordinate care, and reduce health and safety risks. Additional Resources 6 Key Findings About Readmissions Social Determinants of Health Z Codes: Important Codes To Know Before Patient’s Discharge 8 Reasons Why Hospitals and Health Systems are Focused on Social Determinants of Health Download ArticleDownload the Entire Issue

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Unlocking the Mystery: Exploring the Differences in Readmission Penalties for the Dual-Eligible

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