These are the 222 hospitals in Medicare’s worst decile for heart-failure readmissions over the three years ending June 2021. Press play and watch where they land in the three years that follow — a window that shares not one patient with the first.
Mean excess readmission ratio of the worst decile of heart-failure hospitals, 2018–21 → 2021–24. The best decile moved the other way: 0.876 → 0.939. Both crowds walked toward 1.00 from opposite sides.
Medicare’s excess readmission ratio divides how often your heart-failure patients came back by how often CMS’s model says patients like yours should have. Above 1.00 is a finding against you, and it is worth up to 3% of your base Medicare pay.
Each dot below is one hospital, placed by its ratio and stacked to keep the crowd readable. Red is the worst decile of the first window — the 222 hospitals with the strongest case against them. Navy is the best decile. Everyone keeps the colour they were given in 2018–21, so the second frame shows where that cohort went, not who the new worst hospitals are.
window 1 of 2 · Jul 2018 – Jun 2021
worst decile, 2018–21 (222)best decile, 2018–21 (222)the other 1,779
worst decile, mean—
best decile, mean—
gap between them—
worst decile now under 1.00—
Hover any dot for the hospital, its discharge counts, and both ratios. Dots keep their colour from window 1, so the second frame shows where that cohort went — not who the new worst hospitals are.
The red crowd did not disperse evenly. It collapsed inward. None of the 222 was below 1.00 in the first window — that’s what put them in the decile. In the second, 63 of them are, on the side of the line where CMS has nothing to say to you. Eight are in the best decile outright.
Only 55 of the 222 are still in the worst decile. That is 25%, against 10% if the grade were pure noise — so there is something real in there, about two and a half times chance. It is just nowhere near a verdict, and the penalty is written as a verdict.
The objection that doesn’t work here
You’d reach for sample size. Small hospitals bounce; that’s the whole of it. It’s the right instinct and on this dataset it comes out backwards — sort these hospitals into five volume groups and the spread of the ratio grows with volume.
Standard deviation of the published heart-failure ratio within each fifth of the volume distribution, current window (2,316 hospitals with a published denominator). A textbook funnel plot slopes the other way.
the 80/20 lens
Small hospitals aren’t steadier — CMS already knows they’re noisy and has dealt with it upstream. The ratio comes out of a hierarchical model that shrinks a low-volume hospital toward the national average before publication, which is why the smallest fifth is pinned near 1.00. So the number on the page has already been smoothed to make it trustworthy, and it still loses 83% of itself over the next three years (r = 0.407 across these 2,223 hospitals). Whatever is left after the smoothing is mostly not a property of the hospital.
what this is not
Three years is long enough for real change. Some of this movement is hospitals actually getting better or worse. The claim here is narrower: you cannot read which from the ratio, and the penalty never asks.
COVID is inside both windows. Window 1 contains the first fifteen months of the pandemic; window 2 contains Delta and Omicron. That is a real shock to readmission patterns and it inflates the movement shown here.
Regression to the mean is expected, not scandalous. Any noisy measure does this. The scandal, if there is one, is that a measure this noisy carries a 3%-of-revenue penalty and gets read as a statement about a hospital’s character.
Penalties are computed within dual-eligibility peer groups (since FY2019). This page compares published ratios, not the penalties that follow from them.
The most suppressed hospitals are missing. CMS publishes 11,720 ratios in the current file and withholds the denominator for 3,683 of them, printing “Too Few to Report” in place of the readmission count. Those hospitals are graded on arithmetic the public is not shown, and they are not on this chart.
Why you already know how to think about this
M&M exists because medicine decided, formally, that the outcome is not allowed to grade the decision. You present the case that went fine and the room takes it apart anyway, because a good result can be built out of luck and a bad one out of nothing you did.
Then the same hospital gets a number like 1.14, and the number arrives with a dollar figure, and nobody runs it through the room.
The hospital at 1.14 that is now at 1.04 has a story about the discharge pathway it rebuilt. Maybe it did. The chart above cannot tell, and neither can the hospital. What the chart can tell you is that 222 hospitals moved an average of 0.09 in the same direction, together, and most of them had no pathway at all.