P&P, Paid & Penalized

Public Medicare data, made visible.

HospitalSoutheast Michigan Surgical Hospital LLC Estimated FY2026 net: $0×

Hospital record · FY2026CCN 230264

1Hospital

Southeast Michigan Surgical Hospital LLC

2Location

Warren, MI (Michigan’s hospitals on the map and in the table) 48091

Macomb County

3Type

Not a teaching hospital · 20 beds · Nonprofit · Urban

4Care Compare stars

Not Available

Overall rating, CMS Care Compare data of July 22, 2026
CMS footnote 16: There are too few measures or measure groups reported to calculate a star rating or measure group score.
Open on Care Compare (opens in a new tab)

5Total HAC Score

−0.0478

As CMS reports it

6Payment reduction

No cut
CMS’s value: No

7Estimated cut

$0
A cut would have been $4K, likely $3⁠–⁠5K estimate

No cut

$0

from this program

For fiscal year 2026, CMS reports a Total HAC Score of −0.0478 for Southeast Michigan Surgical Hospital LLC and a payment reduction decision of No.

A cut would have taken about $4K estimate 1% of about $365K, this site’s estimate of what traditional Medicare pays it for inpatient stays in a year. Its score was 0.4277 under 0.3799, the lowest score CMS cut.

Likely range $3–5K

Its score was at or below CMS’s line, so this program did not cut its Medicare payments for the year. The score compares hospitals with each other; it is not a grade of the quality of care.

CMS cut scores of 0.3799 and above.

Each year CMS cuts the hospitals with the highest quarter of scores, those above the 75th percentile, so the line moves with other hospitals’ scores.

highest 2.3133 1% cut Middle hospital: −0.0453 Middle hospital−0.0453 CMS’s line: 0.3799 and up CMS’s line0.3799 and up This hospital: −0.0478 This hospital −0.0478 lowest −1.4728 highest 2.3133 1% cut Middle hospital: −0.0453 Middle hospital−0.0453 CMS’s line: 0.3799 and up CMS’s line0.3799 and up This hospital: −0.0478 This hospital −0.0478

Higher than 49% of the other 2,928 scores CMS published (higher is worse).

Its record, fiscal years 2015 to 2026 Cut in 2 of 11 years

  1. 15No
  2. 16No
  3. 17No
  4. 18No
  5. 19No
  6. 20No
  7. 21No
  8. 22No
  9. 23—
  10. 24Cut
  11. 25Cut
  12. 26No

CMS scored this hospital on a single measure, so that measure alone set its Total HAC Score.

Where the score came from

CMS scored this hospital on 1 of the 6 measures. On every measure a lower value is better. Each row puts the hospital among every hospital with a value: the gray columns are those hospitals, the tall tick is the national median, and the hatched ends score the same as CMS’s floor or cap.

Bringing PSI 90 down to the national median (0.9623) would lower the score the most: by 0.1347, to −0.1825. Try it in the what-if

Figure 1. This hospital has a published value for one measure, PSI 90, and it is above the national median.
  • This hospital
  • National median
  • Scores the same as CMS’s floor or cap
  1. PSI 90 (what it counts)

    Safety problems such as serious bedsores, falls that break a bone and blood clots after surgery, found by CMS in traditional Medicare claims. A value of 1 matches the national composite value.

    Patient safety and adverse events composite

    Worse than 59% of the other 2,808 hospitals

    estimate

    This site recomputes this measure’s z‑score from CMS’s published value. The recompute can differ from CMS’s z‑score by up to 0.0021. How this site estimates

    CMS value0.9816

    Z-score−0.0478

    Part of score−0.0478

  2. CLABSI (what it counts)

    Bloodstream infections tied to a central line, a tube often placed in a large vein in the neck, chest or groin. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Central line–associated bloodstream infections

    Not scored on this measure

    CMS footnote 13: Results cannot be calculated for this reporting period.

    CMS footnote 5: Results are not available for this reporting period.

    CMS valueno value published

    Z-scoreno value published

    Part of scoreno value published

  3. CAUTI (what it counts)

    Urinary tract infections that start from a urinary catheter, a tube that drains the bladder. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Catheter-associated urinary tract infections

    Not scored on this measure

    CMS footnote 13: Results cannot be calculated for this reporting period.

    CMS footnote 5: Results are not available for this reporting period.

    CMS valueno value published

    Z-scoreno value published

    Part of scoreno value published

  4. SSI (what it counts)

    Deep infections at the site of colon surgery or an abdominal hysterectomy, within a month of the operation, pooled into one measure. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Surgical site infections after colon surgery or abdominal hysterectomy

    Not scored on this measure

    CMS footnote 12: This measure does not apply to this hospital for this reporting period.

    CMS footnote 5: Results are not available for this reporting period.

    CMS valueno value published

    Z-scoreno value published

    Part of scoreno value published

  5. CDI (what it counts)

    C. diff infections, which cause diarrhea and inflammation of the colon, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Clostridioides difficile (C. diff) infections

    Not scored on this measure

    CMS footnote 13: Results cannot be calculated for this reporting period.

    CMS footnote 5: Results are not available for this reporting period.

    CMS valueno value published

    Z-scoreno value published

    Part of scoreno value published

  6. MRSA (what it counts)

    Bloodstream infections with MRSA, a germ that resists several antibiotics, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    MRSA bloodstream infections

    Not scored on this measure

    CMS footnote 13: Results cannot be calculated for this reporting period.

    CMS footnote 5: Results are not available for this reporting period.

    CMS valueno value published

    Z-scoreno value published

    Part of scoreno value published

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureCMS valueNational medianZ-scorePart of the scoreAmong hospitals
PSI 900.98160.9623−0.0478−0.0478Worse than 59% of the other 2,808 hospitals
CLABSIno value published0.559no value publishedno value publishedNot scored on this measure
CAUTIno value published0.489no value publishedno value publishedNot scored on this measure
SSIno value published0.795no value publishedno value publishedNot scored on this measure
CDIno value published0.346no value publishedno value publishedNot scored on this measure
MRSAno value published0.641no value publishedno value publishedNot scored on this measure

How the parts add up

CMS adds the z‑scores and divides by the number of measures scored, so each measure counts the same. Each bar below is one z‑score divided by 1; a bar right of zero raised the score and one left of zero lowered it.

(−0.0478PSI 90)÷1measures=−0.0478Total HAC Score

Added from the rounded z‑scores CMS published, the parts make −0.0478; CMS reports −0.0478. The small difference is rounding.

This hospital’s score is 0.4277 below 0.3799, the lowest score CMS marked Yes. (This site recomputes.)

Figure 2. The parts add up to −0.0478, below CMS’s line.
1% cut PSI 90: z‑score −0.0478 divided by 1 = −0.0478PSI 90−0.0478 Total HAC Score: −0.0478Score−0.0478 CMS’s line: between 0.3792 and 0.3799 CMS’s line −0.10.00.10.20.30.4 1% cut PSI 90: z‑score −0.0478 divided by 1 = −0.0478PSI 90−0.0478 Total HAC Score: −0.0478Score−0.0478 CMS’s line: between 0.3792 and 0.3799 CMS’s line −0.10.00.10.20.30.4

This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureZ-scorePart of the scoreRunning total
PSI 90−0.0478−0.0478−0.0478
Total HAC Score−0.0478
CMS’s line0.37920.3799

The money is a cliff

This program’s cut doesn’t grow with the score. Over CMS’s line, CMS cuts 1% of what traditional Medicare pays a hospital for inpatient stays that year; at or under the line, this program cuts nothing.

The chart draws what the cut would be for this hospital at any Total HAC Score, from this site’s estimate of its payments, with its own score marked.

Figure 3. The cut is a cliff, not a slope: this hospital’s score, 0.4277 under the lowest score CMS cut, costs it nothing; 0.4277 higher, the cut would have been about $4K by this site’s estimate, the same as at CMS’s highest score, 2.3133.
CMS’s line $0 at any score up to 0.3792 $4K at any score from 0.3799 $0at any score up to 0.3792 $4K at any score from 0.3799 −1012 CMS’s highest score: 2.3133 CMS’s highest score 2.3133 This hospital: −0.0478 This hospital −0.0478 CMS’s line $0 at any score up to 0.3792 $4K at any score from 0.3799 $0at any score up to 0.3792 $4Kat any score from 0.3799 −1.0−0.50.00.51.01.52.0 CMS’s highest score: 2.3133 CMS’s highest score 2.3133 This hospital: −0.0478 This hospital −0.0478

Under the axis, every Total HAC Score CMS published: 306 of the 2,929 scored within 0.1 of CMS’s line, on one side or the other.

Estimate · Source: this site’s arithmetic on CMS’s FY2026 IPPS final rule files (the impact file, the rate tables and the value-based factors), its FY2026 HRRP supplemental file and HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
ScoreTotal HAC ScoreEstimated HAC cut (whole dollars)
Any score up to 0.37920.3792$0
Any score from 0.37990.3799−$3,654
This hospital−0.0478$0
CMS’s highest score2.3133−$3,654

The money, line by line

This site estimates what traditional Medicare pays the hospital for a year of inpatient stays, from CMS’s FY2026 payment files, then applies Medicare’s three hospital quality programs: the readmissions and value-based adjustments to the base payment, and the HAC cut last, as the law sets.

The readmissions and value-based programs adjust only the base payment: the DRG rates times the hospital’s cases, and a Medicare-dependent hospital’s add-on. The HAC cut comes last and takes 1% of everything left, teaching, low-income-patient, outlier, capital and uncompensated care payments included.

($365,418payment+$0readmissions+$0value-based)×1%the cut=$3,654at stake

$3,654at stake÷18traditional Medicare stays=$203per traditional Medicare stay

Figure 4. No HAC cut this year; 1% of the hospital’s whole inpatient payment would have been about $4K by this site’s estimate. The readmissions and value-based adjustments, on the base alone, came to $0 and $0.

Estimated Medicare inpatient payments · FY2026 estimate

What traditional Medicare pays it for inpatient stays
DRG payments at the federal rates the base $329,868
Many low-income patients (disproportionate share) $9,896
Capital: buildings and equipment $25,530
Uncompensated care $124
Total, before the three programs $365,418
The three programs: two on the base, the HAC cut last
Readmissions (HRRP) base × (1.0000 − 1) $0
Value-based purchasing (HVBP) not in CMS’s value-based factors: no adjustment $0
After these two $365,418
HAC Reduction Program no cut; 1% would have been $3,654 $0
Net of the three programs $0

Not paid to this hospital: a Medicare-dependent hospital add-on, teaching payments, outlier payments, a sole community hospital rate difference, and a low-volume adjustment.

Whole dollars, so every line adds up; the estimate is not that precise. Each likely range spans the middle 80% of the misses this site’s estimate made for similar hospitals (or for a wider group, where there were too few) when it was checked against their FY2024 cost reports: one year’s check, not a promise of how often a hospital’s actual figure lands inside.

Estimate · Source: this site’s arithmetic on CMS’s FY2026 IPPS final rule files (the impact file, the rate tables and the value-based factors), its FY2026 HRRP supplemental file and HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
LineAmount (whole dollars)
DRG payments at the federal rates (the base)$329,868
Many low-income patients (disproportionate share)$9,896
Capital: buildings and equipment$25,530
Uncompensated care$124
Total, before the three programs$365,418
Readmissions (HRRP) (base × (1.0000 − 1))$0
Value-based purchasing (HVBP) (not in CMS’s value-based factors: no adjustment)$0
After these two$365,418
HAC Reduction Program (no cut; 1% would have been $3,654)$0
Net of the three programs$0

What if a measure were different?

Change a measure’s value to see how this site recomputes the Total HAC Score, the payment reduction decision and, by its estimate, the money, starting from CMS’s values. The money doesn’t slide with the score: it drops off a cliff at CMS’s line.

The what-if needs JavaScript. Without it, the values below stay as they are.

Show table
CMS reportsHypothetical
Total HAC Score−0.0478same
Payment reduction decisionNosame
Payment cut0%same
Estimated HAC cut estimate$0same

CMS’s line: between 0.3792 and 0.3799

The faint ticks are CMS’s line in earlier years under the same formula, from about 0.300 (FY2022) to about 0.375 (FY2024). The line moves every year, so a hospital can cross it without changing anything.

CMS reports a Total HAC Score of −0.0478 and a payment reduction decision of No.

A what-if shows the formula’s arithmetic, not what a hospital could realistically change or how. CMS’s real result also depends on other hospitals.

How much cushion?

Staying at or under CMS’s line keeps about $4K out of this program’s cut, this site estimates: a score a hair over would cost all of it.

From CMS’s values, one measure at a time, with every other measure held at CMS’s value.

MeasureHighest value that keeps No
PSI 90up to 1.0426

Each measure weighs 1 ÷ 1 of the score.

Measure values

SIR 1.0 = as many infections as predicted · Lower is better

On each track the tick is the national median; shaded values score the same as the floor or cap, as this site fits them to CMS’s values.

CMS 0.9816 · median 0.9623 · floor 0.7760 · cap 1.3482 · each 0.1 = 0.6981

Figure 5. Each bar is one measure’s part of this hospital’s Total HAC Score of −0.0478: its z‑score divided by 1, the number of measures scored.
  • PSI 90 −0.0478

A measure adds its z‑score divided by 1, the number of measures scored. Bars right of the center line raise the score. Hatched: assigned by CMS.

This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureZ-scorePart of the scoreHypothetical
PSI 90−0.0478−0.0478same

Interactive what-if at https://paidandpenalized.org/hacrp/hospital/230264/

Among hospitals with a Yes or No payment decision, CMS cut those with a published Total HAC Score of 0.3799 or higher and none at 0.3792 or lower. Maryland’s hospitals are scored but not subject to the reduction.

Held fixed: every other hospital’s results, CMS’s line, and each measure’s mean, spread, floor and cap as this site fits them to CMS’s published values.

Year by year

Where this hospital’s score fell among every hospital’s, each year CMS published one. A score near the top is among the highest; the shaded band is where CMS cut. Places compare across years even where CMS changed how it builds the score.

Its longest run: cut 2 years in a row.

Figure 6. CMS cut this hospital in 2 of the 11 years it made a decision.
highest middle lowest z‑scoresequal weights no scores FY2015: score 7.0000, higher than 73% of scores; not cutFY2016: score 6.0000, higher than 56% of scores; not cutFY2017: score 6.0000, higher than 62% of scores; not cutFY2018: score −0.1423, higher than 40% of scores; not cutFY2019: score −0.0049, higher than 51% of scores; not cutFY2020: score 0.0115, higher than 53% of scores; not cutFY2021: score 0.0328, higher than 55% of scores; not cutFY2022: score 0.0178, higher than 54% of scores; not cutFY2024: score 2.1665, higher than 98% of scores; cutFY2025: score 1.0742, higher than 95% of scores; cutFY2026: score −0.0478, higher than 49% of scores; not cut 161820222426 highest middle lowest z‑scoresequal weights no scores FY2015: score 7.0000, higher than 73% of scores; not cutFY2016: score 6.0000, higher than 56% of scores; not cutFY2017: score 6.0000, higher than 62% of scores; not cutFY2018: score −0.1423, higher than 40% of scores; not cutFY2019: score −0.0049, higher than 51% of scores; not cutFY2020: score 0.0115, higher than 53% of scores; not cutFY2021: score 0.0328, higher than 55% of scores; not cutFY2022: score 0.0178, higher than 54% of scores; not cutFY2024: score 2.1665, higher than 98% of scores; cutFY2025: score 1.0742, higher than 95% of scores; cutFY2026: score −0.0478, higher than 49% of scores; not cut 151617181920212223242526

● Red: a year CMS cut it ○ Hollow: a year it didn’t

This site recomputes · Source: CMS, HACRP hospital files for fiscal years 2015 to 2026 (Provider Data Catalog, its archives and, for the oldest years, the Internet Archive’s copies), and CMS’s cut lists for FY2015 and FY2016.

Show table
Fiscal yearTotal HAC ScoreHigher than this share of scoresPayment reduction
FY20157.000073.6%not cut
FY20166.000056.2%not cut
FY20176.000062.8%not cut
FY2018−0.142340.6%not cut
FY2019−0.004951.7%not cut
FY20200.011553.4%not cut
FY20210.032855.2%not cut
FY20220.017854.1%not cut
FY2023no decision
FY20242.166598.5%cut
FY20251.074295.0%cut
FY2026−0.047849.6%not cut

Among hospitals like it

Each row is a group this hospital belongs to, drawn from every hospital in it with a payment decision. Red columns are hospitals past CMS’s line, the ones CMS cut; the short tick is the group’s middle score.

In Michigan, its score is higher than 44% of the other 87 scored there.

In Warren-Troy-Farmington Hills, MI area, its score is higher than 50% of the other 20 scored there.

Figure 7. Its score is above the middle in 3 of the 8 groups it belongs to; the share cut runs from 23% (Urban) to 34% (Michigan).
All hospitals: CMS cut 718 of 2,886 (25%); middle score −0.0453All hospitals 2,886 hospitals25% cut Midwest region: CMS cut 174 of 683 (25%); middle score −0.0268Midwest region 683 hospitals25% cut Michigan: CMS cut 30 of 88 (34%); middle score 0.0204Michigan 88 hospitals34% cut Warren-Troy-Farmington Hills, MI area: CMS cut 7 of 21 (33%); middle score −0.0478Warren-Troy-Farmington Hills, MI area21 hospitals33% cut Not teaching: CMS cut 389 of 1,563 (25%); middle score −0.1053Not teaching 1,563 hospitals25% cut Fewer than 100 beds: CMS cut 225 of 805 (28%); middle score −0.1154Fewer than 100 beds 805 hospitals28% cut Nonprofit: CMS cut 478 of 1,830 (26%); middle score −0.0134Nonprofit 1,830 hospitals26% cut Urban: CMS cut 510 of 2,241 (23%); middle score −0.0574Urban 2,241 hospitals23% cut CMS’s line: between 0.3792 and 0.3799 CMS’s line −1012 This hospital: −0.0478 This hospital −0.0478 All hospitals: CMS cut 718 of 2,886 (25%); middle score −0.0453All hospitals2,886 hospitals25% cut Midwest region: CMS cut 174 of 683 (25%); middle score −0.0268Midwest region683 hospitals25% cut Michigan: CMS cut 30 of 88 (34%); middle score 0.0204Michigan88 hospitals34% cut Warren-Troy-Farmington Hills, MI area: CMS cut 7 of 21 (33%); middle score −0.0478Warren-Troy-Farmington Hills, MI area21 hospitals33% cut Not teaching: CMS cut 389 of 1,563 (25%); middle score −0.1053Not teaching1,563 hospitals25% cut Fewer than 100 beds: CMS cut 225 of 805 (28%); middle score −0.1154Fewer than 100 beds805 hospitals28% cut Nonprofit: CMS cut 478 of 1,830 (26%); middle score −0.0134Nonprofit1,830 hospitals26% cut Urban: CMS cut 510 of 2,241 (23%); middle score −0.0574Urban2,241 hospitals23% cut CMS’s line: between 0.3792 and 0.3799 CMS’s line −1.5−1.0−0.50.00.51.01.52.0 This hospital: −0.0478 This hospital −0.0478

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
GroupWith a decisionHospitals cutShare cutMiddle scoreHospital higher than
All hospitals2,88671825%−0.045349%
Midwest region68317425%−0.026848%
Michigan883034%0.020444%
Warren-Troy-Farmington Hills, MI area21733%−0.047850%
Not teaching1,56338925%−0.105353%
Fewer than 100 beds80522528%−0.115452%
Nonprofit1,83047826%−0.013447%
Urban2,24151023%−0.057450%
This hospital−0.0478
CMS’s line0.37920.3799

The nearest hospitals

The 8 closest hospitals with a Total HAC Score, in a straight line. The squares are each hospital’s measures in order: filled, above the national median; open, at or below it; hatched, assigned by CMS; blank, not scored.

Figure 8. CMS cut 3 of the 8 nearest hospitals; the closest is 5 miles away.
5 mi8. Harper University Hospital, Detroit: score 0.6458, cut, 7 miles87. Karmanos Cancer Center, Detroit: score 0.2902, not cut, 7 miles76. Detroit Receiving Hospital, Detroit: score 0.6721, cut, 7 miles65. Ascension Providence Hospital, Southfield and Novi, Southfield: score −0.4037, not cut, 6 miles54. Surgeons Choice Medical Center, Southfield: score −0.1976, not cut, 6 miles43. Henry Ford Health Hospital, Detroit: score 0.1266, not cut, 6 miles32. Henry Ford Health Warren Hospital, Warren: score −0.1115, not cut, 6 miles21. Sinai-Grace Hospital, Detroit: score 0.7718, cut, 5 miles1This hospital: Southeast Michigan Surgical Hospital LLC

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
HospitalMilesScoreDecision
Sinai-Grace Hospital, Detroit, MI50.7718cut
Henry Ford Health Warren Hospital, Warren, MI6−0.1115not cut
Henry Ford Health Hospital, Detroit, MI60.1266not cut
Surgeons Choice Medical Center, Southfield, MI6−0.1976not cut
Ascension Providence Hospital, Southfield and Novi, Southfield, MI6−0.4037not cut
Detroit Receiving Hospital, Detroit, MI70.6721cut
Karmanos Cancer Center, Detroit, MI70.2902not cut
Harper University Hospital, Detroit, MI70.6458cut

#HospitalMilesScoreDecisionEst. cut ($, modeled)Measures
1Sinai-Grace HospitalDetroit, MI50.77181% cut$560KAbove the national median on 5 of 6 measures
2Henry Ford Health Warren HospitalWarren, MI6−0.1115No cut$0Above the national median on 3 of 6 measures
3Henry Ford Health HospitalDetroit, MI60.1266No cut$0Above the national median on 3 of 6 measures
4Surgeons Choice Medical CenterSouthfield, MI6−0.1976No cut$0Above the national median on 0 of 1 measures
5Ascension Providence Hospital, Southfield and NoviSouthfield, MI6−0.4037No cut$0Above the national median on 2 of 6 measures
6Detroit Receiving HospitalDetroit, MI70.67211% cut$551KAbove the national median on 4 of 6 measures
7Karmanos Cancer CenterDetroit, MI70.2902No cut$0Above the national median on 3 of 5 measures
8Harper University HospitalDetroit, MI70.64581% cut$500KAbove the national median on 5 of 6 measures

Download all hospitals’ data (CSV) · Data dictionary · CMS’s dataset page

CMS’s footnotes on this page

13
Results cannot be calculated for this reporting period.
5
Results are not available for this reporting period.
12
This measure does not apply to this hospital for this reporting period.

How the program works, and how to find another hospital

A penalty reflects how CMS’s formula scored relative performance; it is not a verdict on the quality of care.

Cite this page

Paid & Penalized. Southeast Michigan Surgical Hospital LLC, Warren, MI: Hospital-Acquired Conditions, FY2026. https://paidandpenalized.org/hacrp/hospital/230264/. Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.