Medicare Just Added $1.9 Billion to Its 2011 Charity Care

On September 24 at 19:09 GMT, CMS wrote a brand new copy of a file it finished fifteen years ago.

The file is CostReport_2011_Final.csv, the public use version of every Medicare hospital cost report for fiscal 2011. The copy CMS had been serving went up on November 3, 2025 and had not moved since.

Same filename, same 201 columns, same Final in the name.

We pulled both copies and joined them on CCN and fiscal period. The national cost of charity care for fiscal 2011 came back $1.86 billion higher than the copy CMS had been serving for ten months.

Only One Block of the Worksheet Moved

Nothing general happened to this file. Total costs across the 6,150 reports in both copies fell $40.5 million on a base of $641 billion, which is a rounding error.

Net income moved $110,000. Bad debt moved $6.4 million.

Every dollar of consequence landed in the uncompensated care block (chart below).

Cost of charity care: $27.19B to $29.05B, up $1.86 billion, or 6.85%.
Cost of uncompensated care: $42.10B to $43.93B, up $1.83 billion.
Total unreimbursed and uncompensated care: $60.25B to $62.06B, up $1.81 billion.
Disproportionate share adjustment: up $49.4 million across 480 reports.

That is Worksheet S-10, and it is the single worksheet on the 2552-10 that still sets money today.

The movement is concentrated. 819 hospitals had their charity care restated, 770 of them upward, and 285 moved by at least a million dollars. Brackenridge Hospital in Austin went from $91.4M to $193.6M on one line. Summa Barberton more than quadrupled, Maimonides nearly tripled, Mercy St. Louis went up $45.2 million. Five hospitals had a dollar figure replaced with a blank cell, UCSD Medical Center among them, which dropped $55.4 million of charity care and now reports none.

A Third of the File Has a New Primary Key

Here is the part that breaks pipelines.

rpt_rec_num is the HCRIS report record number, the key every cost report extract joins on. In the new copy, 2,001 of the 6,150 reports carry a different one.

Same hospital, same fiscal period, usually the same data, fresh key.

"What happens to a panel whose join column gets reissued under it?"

So if you keep a 2011 hospital panel keyed on the record number, roughly a third of it stopped matching on September 24 and nothing told you. Two hospitals also showed up that were never in the file at all: Georgiana Hospital in Alabama and Baptist Hospital of Cocke County in Tennessee, both filing their 2011 cost report into a 2026 refresh.

The controls matter here. We ran the same diff on the 2011 skilled nursing file and the 2020 home health file, both reposted in the same sweep.

The SNF file is byte for byte identical to the November 2025 copy, same MD5, new storage path. Home health added four reports and changed zero values.

The hospital series is the one CMS restated.

2011 Is Not the Year to Worry About

CMS rewrote all 33 cost report files it publishes between September 18 and October 2, in two waves, then moved the catalog flags on September 30 and October 5.

Four of those files are the hospital vintages for FY 2021 through FY 2024, written on October 2 between 13:22 and 13:38 GMT.

FY 2021, FY 2022 and FY 2023 are exactly the three years of S-10 data CMS used to build Factor 3 of the FY 2027 uncompensated care payment: $11,825,250,000 of Factor 1, a Factor 2 of 67.14%, and roughly $7.94 billion going out the door on discharges dated October 1 and later. Those files got rewritten six days ago.

We cannot tell you what changed inside them. No prior copy of those three is recoverable from the catalog snapshots that exist, so we are not going to pretend otherwise.

What the 2011 file establishes is the behavior: CMS will silently restate S-10 in a file stamped Final, and the restatement runs one direction.

Final Thoughts

The practical move is small and worth doing this week. If any model you own reads a cost report public use file, stamp it: the storage path carries the year and month, the HTTP last modified header carries the day, and those are the only version string a CMS download gives you.

A file named Final sat still for ten months and then changed, and the only notice was a timestamp.

The deeper read is about what Final means at CMS. Settlements reopen, audits land, intermediaries amend, and the public file eventually catches up, which is reasonable.

A silent catch-up fifteen years later, on the one worksheet that distributes eight billion dollars a year, is a different thing. It means the number in your deck and the number on cms.gov agree only on the day you downloaded it.

Thanks for reading.