Plan All-Cause Readmissions (PCR)

Assesses the rate of adult acute inpatient and observation stays that were followed by an unplanned acute readmission for any diagnosis within 30 days after discharge. As well as reporting observed rates, NCQA also specifies that plans report a predicted probability of readmission to account for the prior and current health of the member, among other factors. A separate readmission rate for hospital stays discharged to a skilled nursing facility is reported for Medicare plans. The observed rate and predicted probability is used to calculate a calibrated observed-to-expected ratio that assesses whether plans had more, the same or less readmissions than expected, while accounting for incremental improvements across all plans over time. The observed-to-expected ratio is multiplied by the readmission rate across all health plans to produce a risk-standardized rate which allows for national comparison.

Why It Matters

A “readmission” occurs when a patient is discharged from the hospital and then admitted back into the hospital within a short period of time. A high rate of patient readmissions may indicate inadequate quality of care in the hospital and/or a lack of appropriate post-discharge planning and care coordination. Unplanned readmissions are associated with increased mortality and higher health care costs. Unplanned readmissions can be prevented by standardizing and improving coordination of care after discharge and increasing support for patient self-management.1

Results

Readmission Rate (18–64 Years)*

Measure YearCommercial HMOCommercial PPOMedicare HMOMedicare PPO
20194.94.7§§
20188.1816.215.7
20178.28.116.116.2
2016881615.7
201510.910.919.517.8
201411.911.922.422.1
20138.58.314.715.1
20129.18.115.115.8
20118.48.3
*Lower rates signify better performance.

Readmission Rate (65 Years and Older)*

Measure YearMedicare HMOMedicare PPO
20181211.9
201712.912.3
201612.912.6
201515.215.7
201417.517.9
201312.712.8
201213.713.7
201114.113.5
*Lower rates signify better performance.

§ Not available due to CMS suspension of data reporting during COVID-19 pandemic.

This State of Healthcare Quality Report classifies health plans differently than NCQA’s Quality Compass. HMO corresponds to All LOBs (excluding PPO and EPO) within Quality Compass. PPO corresponds to PPO and EPO within Quality Compass.

Figures do not account for changes in the underlying measure that could break trending. Contact Information Products via my.ncqa.org for analysis that accounts for trend breaks.

References

  1. Boutwell, A., F. Griffin, S. Hwu, D. Shannon. 2009. “Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions.” Cambridge, MA. Institute for Healthcare Improvement.

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