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Medicaid patients far more likely to be readmitted
One of every 10 adult Medicaid patients hospitalized in 2007 for a medical condition other than childbirth had to be readmitted at least once within 30 days, according to an April 2010 report from the Rockville, MD-based Agency for Healthcare Research and Quality (AHRQ), All-Cause Hospital Readmission Rates among Non-Elderly Medicaid Patients, 2007. The report uses statistics generated from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases for 10 states.
Medicaid patients were 70% more likely to be readmitted than the privately insured, mainly due to underlying health problems. "Some of the findings were not particularly surprising. They echo what we knew already from the literature," says study author H. Joanna Jiang, PhD, a senior social scientist at AHRQ's Center for Delivery, Organization and Markets.
For example, an AHRQ study done several years ago compared readmissions for diabetes-related conditions among payer groups. The 30-day readmission rate was 11% for Medicaid compared to 8% for the privately insured, similar to the April 2010 report's findings. Another previous AHRQ study found that the risk for readmission increases substantially with the number of co-existing conditions, particularly if they are chronic. That finding also was confirmed in the new report.
However, Dr. Jiang says that "a few other findings were quite revealing, and not found in previous studies." For instance, Medicaid patients who were hospitalized for conditions that fall under five particular categories of disease accounted for more than half of the 30-day readmissions.
"This tells us which conditions or patient groups we would want to target, if we want to reduce readmissions," says Dr. Jiang. "Given a 10% readmission rate for the non-OB population, there is significant room for improvement, particularly in view of the gap in comparison to the privately insured."
Readmission is mentioned "almost everywhere" in the health care reform bill," says Dr. Jiang.
"This is definitely an area of focus in the coming years," she adds. "Facing the prospect of expansion in the Medicaid program with shrinking state budgets, tackling hospital readmissions may be an effective way to improve quality while reducing cost."
David Brody, MD, medical director of the Department of Managed Care at Denver (CO) Health Medical Center, says he wasn't surprised by the AHRQ statistics on Medicaid readmissions. "I think there are a number of factors that contribute to that," he says. "In the Medicaid population, you see more homelessness, you see more serious mental illness, and you see more substance abuse."
Dr. Brody adds that in his experience, a small number of patients who are very frequent readmitters contribute substantially to the readmission rate. "You provide whatever services are available, but at the end of the day, it's very difficult to have an impact on that population," he says.
Health care reform may have a positive impact on this. "To the extent that Medicaid eligibility is determined more by economic factors than chronic disease, I think we may see a trend toward the readmission rates looking more like the general population," says Dr. Brody. "But even under the best of circumstances, there is a core group of patients that are very difficult to keep out of the hospital." This is because in addition to whatever problem brought an adult Medicaid patient into the hospital, that patient is likely to have multiple comorbidities.
In Colorado, mental health services are "carved out" to managed care behavioral health organizations. "The disconnect between the mental health problems and the physical health problems makes it more challenging to treat," says Dr. Brody. "We don't pay for the treatment of the mental health problems, yet those mental health problems are contributing to our readmissions on the physical health side."
Access can be a more difficult challenge for Medicaid patients to begin with, either due to the availability of appointments or difficulty in navigating the system. This could be a contributing factor with avoidable readmissions. As for how the expansion of Medicaid will impact the ability to access care, Dr. Brody calls this "a big unknown."
"If the number of patients increase without a corresponding increase in providers, it could be even more challenging," says Dr. Brody. "On the other hand, if more patients are enrolled and more providers are available to see them, it could be easier."
Denver Health's nurse care managers routinely contact patients within 48 to 72 hours after discharge to find out if there are any obstacles in following treatment plans. "We identify lots of problems we can help patients with, although I'm not entirely convinced we have actually had much impact on the readmission rate," says Dr. Brody. "So our next step is to more aggressively do home assessments, both before discharge to be sure the home is a safe place to discharge them to, as well as after discharge."