Care coordination

Read it this way The 40.5 percent slice combining the 4-to-5 and 6-or-more segments represents beneficiaries whose care realistically spans multiple providers. This is a single 2015 snapshot of the whole Medicare fee-for-service population. It does not show how condition burden is distributed within any one region or plan. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

CMS Chronic Conditions Warehouse, condition-count distribution · 2015 · source

Read it this way The line climbs steadily from 14.0 percent in 2010 to 17.3 percent in 2015 with no year showing a decline, supporting the claim that the most complex patient tier is growing. Because a 2022 figure is not published in the sources reviewed, the chart cannot show whether that climb continued at the same pace afterward. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

Caveat The 2022 value is not published in the sources reviewed, so it is not plotted. Pre-2015 figures use slightly different CMS definitions and are approximate. Partial 2022 data suggests the share has grown beyond 17.3 percent.

CMS Chronic Conditions Chartbook and Goodman et al., Annals of Internal Medicine · 2015 · source

Read it this way Hypertension and hyperlipidemia dominate at 66.8 and 65.5 percent, each affecting roughly two-thirds of beneficiaries, which is why they anchor the comorbidity mix coordination has to manage. Two of the ten figures carry a caveat: ischemic heart disease uses a 2021 figure rather than 2022, and heart failure includes under-65 disabled enrollees, so treat comparisons involving those two conditions as approximate. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

Caveat Ischemic heart disease is a 2021 figure. Heart failure includes under-65 disabled enrollees. Depression rounds a CCW-reported 17.54 percent.

CMS Chronic Conditions Warehouse, Table B.2.a · 2022 · source

Read it this way Hyperlipidemia, BPH, and osteoporosis rose over the five years while hypertension, COPD, and dementia edged down, so the comorbidity mix is shifting rather than growing uniformly across the board. Depression is left out because its 2017 figure isn't published, so this chart cannot speak to whether depression prevalence changed over the same period. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

Caveat Depression is excluded because its 2017 CCW value is not published. Benign prostatic hyperplasia is among male beneficiaries only.

CMS Chronic Conditions Warehouse, Table B.2.a · 2022 · source

Read it this way The 27-point gap between the capability line at 70 percent and the routine-use line at 43 percent in 2023 shows hospitals increasingly can exchange records across all four domains but mostly do not do so as routine practice. This chart identifies the size of that practice gap. It does not show why capable hospitals aren't using it routinely. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

Caveat The survey skipped 2020. Values are from the ONC and American Hospital Association Information Technology Supplement.

ONC Data Brief, Interoperability among US Non-Federal Acute Care Hospitals · 2023 · source

Read it this way Send sits highest at 92 percent and Receive follows at 87 percent, while Find at 84 percent and Integrate at 78 percent lag furthest behind, so those two steps are where a record handoff is most likely to break down. This is a national average across all four steps. It does not show whether the same hospitals struggle with both Find and Integrate or whether different hospitals are weak on different steps. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

ONC Data Brief, Interoperability among US Non-Federal Acute Care Hospitals · 2023 · source

Read it this way Providers are named in 81.8 percent of claims versus 17.2 percent for health IT developers, which cuts against a story where vendors are the primary source of blocked information. These are unverified allegations, not adjudicated findings, and a single claim can name more than one actor, so the shares describe who gets accused, not who is proven at fault. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

Caveat These are unverified allegations, not adjudicated findings, and a single claim can name more than one actor. Shares are of identifiable actor associations.

ONC Information Blocking Claims Portal, Health IT Feedback · 2026 · source

Read it this way Most states cluster well above the 81.5 percent national benchmark, several near 100 percent, while New Hampshire at 23.8 percent stands out as a clear outlier alongside South Carolina at 51.3 and Alabama at 56.1. This map shows HIO participation only. A state near 100 percent here is not necessarily also near the top on the TEFCA map next to it. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

ONC, Hospital Health Information Exchange and TEFCA Participation · 2025 · source

Read it this way TEFCA participation ranges from Florida's 66.4 percent down to Delaware and North Dakota at 0 percent, around a national rate of just 34.3 percent, well below HIO participation. Compare this against the HIO tile map rather than assuming the two track together: several states with near-universal HIO participation still show low TEFCA adoption, since the two systems are largely uncorrelated. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

ONC, Hospital Health Information Exchange and TEFCA Participation · 2025 · source

Read it this way All six ratios sit only fractionally above the 1.0 peer-group median, from 1.0008 for COPD to 1.0052 for hip and knee replacement, so no single condition is dramatically driving excess readmissions. This tightness shows hospitals cluster close to the benchmark, but it does not say whether that benchmark itself is demanding or lenient. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

CMS Hospital Readmissions Reduction Program Dataset · FY2024 · source

Read it this way The penalized share stays near 80 percent every year except FY2023, when it drops to 75 percent because of COVID-19 measurement adjustments, including the excluded pneumonia measure that year, not because hospitals suddenly performed better. Read the FY2023 dip as a measurement artifact rather than a real one-year improvement. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

Caveat The FY2023 dip reflects COVID-19 measurement adjustments, including exclusion of the pneumonia measure that year.

CMS QualityNet, HRRP Overview · FY2024 · source

Read it this way Total withheld penalties fell from 564 million dollars in FY2018 to 320 million in FY2023, but only these four years have a publicly aggregated total, so this is not a complete year-by-year series and the drop could partly reflect which years happen to be published rather than a true trend. Use this chart to see which coordination failure is being measured, patient complexity, readmissions, or information flow, and how it supports the recommendation for accountable handoffs.

KFF, 10 Years of Hospital Readmissions Penalties · FY2023 · source