The Question No One’s Asking About Hospital RTA Metrics
Everyone in post-acute care (PAC) is bracing for impact. Hospitals started tracking six specific ICD-10 diagnosis categories for return to acute in early 2025, and the entire industry is nervously waiting for the regulatory hammer to drop.
The six new tracking categories include: Acute Myocardial Infarction (AMI), Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Pneumonia, Coronary Artery Bypass Graft (CABG) Surgery, or Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA) and their respective ICD-10 codes.
The consensus? This is another compliance burden, another quality measure to game, another reason this industry gets blamed for healthcare system failures.
Here’s the contrarian take: what if these six diagnosis codes are actually the most valuable market intelligence hospitals have ever handed us?
We’ve Been Asking the Wrong Question
The industry conversation goes like this: “How do we avoid penalties when these become post-acute care quality measures?”
The better question: “Why are hospitals suddenly interested in these specific six diagnoses for return to acute?”
Think about it. CMS and hospital systems didn’t randomly select these codes. They represent something specific: the conditions where post-acute placement decisions have the highest financial and clinical stakes for hospitals. These are the diagnoses where hospitals are hemorrhaging money on readmissions, where patients are cycling through the revolving door, where care transitions are breaking down most expensively.
In other words, these six diagnosis categories represent exactly where hospitals are most desperate for reliable post-acute care partners.
The Hidden Message in Hospital Metrics
When a hospital starts measuring something, they’re revealing what keeps their CFO and CMO up at night. These six ICD-10 codes are essentially a treasure map showing you exactly which patient populations hospitals need you to manage successfully.
This isn’t a threat; it’s an invitation to partnership on the terms that matter most to your referral sources.
Consider what happens when you flip the script:
Traditional PAC approach: “We need to avoid readmissions in these categories to protect our star rating.”
Strategic PAC approach: “We need to demonstrate excellence in these categories because they’re precisely what makes us valuable to hospital partners in value-based arrangements.”
Why “Readmission Prevention” Misses the Point
Here’s where the industry has it backwards: the goal isn’t zero readmissions. The goal is appropriate acute care utilization.
Some patients in these six diagnosis categories should return to the hospital because they’re experiencing acute clinical deterioration that requires hospital-level intervention. Trying to manage a truly acute issue at the post-acute care level to avoid a “readmission” metric isn’t good care; it’s dangerous care.
What hospitals actually want (and what value-based care actually rewards) is post-acute care that can:
- Accurately risk-stratify which patients in these categories are stable enough for post-acute level care
- Provide appropriate clinical management that prevents avoidable deterioration
- Recognize early decompensation and transfer before patients become critically ill
- Successfully transition patients home where other post-acute care providers would send back to acute
That’s a completely different competency set than “keep everyone out of the hospital no matter what.”
The Admission Decision Is the Intervention
Most post-acute care providers are thinking about these six diagnosis codes as a discharge problem. How do we keep these patients from bouncing back?
The more sophisticated insight: This is an admission problem. The critical decision point is whether to accept these patients from the hospital in the first place.
This is where your data infrastructure becomes a competitive weapon. If you’re tracking outcomes by diagnosis category, you can answer questions like:
- Which of these six diagnoses do we consistently manage well versus poorly?
- Are certain hospital partners sending us patients in these categories who are actually too acute for post-acute level care?
- What patient characteristics within each diagnosis predict a successful post-acute care course versus return to acute?
This intelligence lets you do something most post-acute care providers can’t: selectively accept the admissions where you add value and decline the ones where you don’t.
In a fee-for-service world, that sounds crazy. Turn down admissions? But in value-based care, getting paid for poor outcomes is worse than not getting paid at all. It destroys your metrics, damages hospital relationships, and ultimately excludes you from the networks that matter.
The Data Infrastructure Most PAC Providers Don’t Have (Yet)
Here’s what separates post-acute care providers that will thrive under these metrics from those that will struggle:
Reactive PAC track: Overall readmission rates
Strategic PAC track: Diagnosis-specific admission volumes, length of stay, discharge disposition, and RTA rates with the ability to stratify by hospital source, payer, patient characteristics, and clinical protocols used
Most critically, strategic post-acute care providers can answer this question in real-time: “A hospital just called with a patient in diagnosis category X. Based on our historical data with this specific hospital for this specific diagnosis, what’s the probability of successful community discharge versus return to acute?”
That’s not a compliance dashboard. That’s business intelligence.
The Partnership Conversation That Changes Everything
Imagine this conversation with your primary hospital referral partner:
“We’ve been analyzing our outcomes for the six diagnosis categories you’re tracking for RTA. We’ve identified that for three of those categories, our community discharge rate exceeds 75% and our return to acute rate is under 15%. For those three diagnoses, we’d like to be your preferred post-acute care partner, and we can demonstrate why with our data.
For the other three categories, we’ve found our outcomes aren’t where they need to be yet. We’re developing enhanced clinical protocols, but in the meantime, we want to be selective about which patients in those categories we accept to ensure we’re only taking patients we can truly help.”
What hospital wouldn’t want to work with a post-acute care provider that talks like this?
From Compliance Theater to Clinical Excellence
The industry’s default response to new quality metrics is compliance theater: teach staff what boxes to check, implement workarounds, hope the penalties aren’t too severe.
But these six diagnosis categories offer something different. They provide a clear roadmap to clinical differentiation.
Instead of asking “How do we avoid penalties?”, ask:
- What would it take to become the regional expert in managing these six conditions?
- What clinical partnerships, staff training, or protocol development would move our outcomes from average to exceptional?
- How do we turn these metrics into marketing assets that demonstrate our value to ACOs, MA plans, and hospital partners?
The Regulatory Wave Is Coming, But So Is the Market Opportunity
Yes, post-acute care regulations tied to these diagnosis categories are almost certainly coming. The pattern is too clear, the precedent too established.
But regulations create market segmentation. When everyone gets measured on the same metrics, performance differences become visible. The post-acute care providers with superior outcomes will have unprecedented leverage in payer negotiations and hospital partnerships.
The question isn’t whether you’ll be measured on these six diagnosis categories. The question is whether you’ll be measured and found excellent, or measured and found wanting.
The Takeaway: Intelligence, Not Compliance
The six ICD-10 codes hospitals are tracking for return to acute aren’t a regulatory threat first. They’re a market signal. They tell you exactly where healthcare systems need competent post-acute partners most desperately.
Build your data infrastructure around these diagnoses not because you’re afraid of penalties, but because you want the intelligence to make better admission decisions, deliver better clinical care, and negotiate better contracts.
By the time these become mandatory post-acute care quality measures, you won’t be scrambling to comply. You’ll be showcasing metrics that demonstrate why you’re indispensable.
The best defense against punitive regulations has always been excellent performance. These six diagnosis categories just made it clearer what excellence looks like.
Does your EHR give you diagnosis-specific outcome tracking? Can you stratify performance by referral source and patient characteristics? The post-acute care providers winning in value-based care aren’t waiting for regulations. They’re building the intelligence infrastructure that makes them irreplaceable partners.
It’s your data – why not use it? Schedule a 15-minute call.