BACKGROUND:

Children insured by Medicaid have higher readmission rates than privately insured children. However, little is known about whether this disparity has changed over time.

METHODS:

Data from the 2010 to 2017 Healthcare Cost and Utilization Project Nationwide Readmissions Database were used to compare trends in 30-day readmission rates for children insured by Medicaid and private insurers. Patient-level crude and risk-adjusted readmission rates were compared by using Poisson regression. Hospital-level risk-adjusted readmission rates were compared between Medicaid- and privately insured patients within a hospital by using linear regression.

RESULTS:

Approximately 60% of pediatric admissions were covered by Medicaid. From 2010 to 2017, the percentage of children with a complex or chronic condition increased for both Medicaid- and privately insured patients. Readmission rates were consistently higher for Medicaid beneficiaries from 2010 to 2017. Readmission rates declined slightly for both Medicaid- and privately insured patients; however, they declined faster for privately insured patients (rate ratio: 0.988 [95% confidence interval: 0.986–0.989] vs 0.995 [95% confidence interval: 0.994–0.996], P for interaction <.001]). After adjustment, readmission rates for Medicaid- and privately insured patients declined at a similar rate (P for interaction = .87). Risk-adjusted hospital readmission rates were also consistently higher for Medicaid beneficiaries. The within-hospital difference in readmission rates for Medicaid versus privately insured patients remained stable over time (slope for difference: 0.015 [SE 0.011], P = .019).

CONCLUSIONS:

Readmission rates for Medicaid- and privately insured pediatric patients declined slightly from 2010 to 2017 but remained substantially higher among Medicaid beneficiaries suggesting a persistence of the disparity by insurance status.

What’s Known on This Subject:

Historically, 30-day readmission rates have been higher for Medicaid- versus privately insured pediatric patients. Recent efforts to reduce readmissions in pediatric patients may have reduced the magnitude of this disparity over time.

What This Study Adds:

Thirty-day readmission rates remained significantly higher for Medicaid beneficiaries than privately insured patients from 2010 to 2017 without a reduction in the disparity over time.

Pediatric readmissions cost the health care system ∼$1.5 billion annually and can pose significant financial burdens. Given their prevalence and cost, hospital readmissions have become a national priority for payers, providers, and policymakers, and considerable attention has been devoted to reducing readmissions.19  Yet, despite these initiatives, crude hospital readmission rates for pediatric patients have increased over time, a phenomenon driven largely by the rising number of patients with complex chronic conditions.10 

Previous studies have reported an increased risk of readmission for children insured by Medicaid when compared with those insured by private insurance.1113  Although the reasons for this observation are unclear, Medicaid beneficiaries may have decreased access to follow-up care or may be more likely to use the emergency department for their usual source of care.14,15  Alternatively, insurance status may serve as a proxy for socioeconomic status and thus reflect other hardships that contribute to adverse outcomes. Finally, a disproportionate percentage of children with medical complexity are covered by Medicaid, which may inflate the risk of readmission in this population.16,17 

Despite changes in the insurance market and national efforts to reduce readmissions, little is known about how the disparity in readmission rates for patients insured by Medicaid versus private insurers has changed over time. Characterizing these trends is useful for informing efforts to reduce readmissions by understanding which populations are at greatest risk and identifying potential etiologies for this increased risk. Accordingly, we analyzed trends in patient- and hospital-level 30-day readmission rates for children insured by Medicaid and private insurers from 2010 to 2017.

We used data from the 2010 to 2017 US Healthcare Cost and Utilization Project Nationwide Readmissions Database (NRD) to obtain national rates of pediatric readmissions. The NRD comprises a nationally representative, weighted probability sample of ∼36 million discharges annually across 18 to 28 geographically dispersed states. Patient identifiers are used to link individuals across hospitalizations within each state. Patients transferred to other hospitals were included in the analysis only once under the second hospitalization. When transfers were present, the NRD collapsed both hospital records into a single record with the admission date from the original hospitalization and the discharge date from the second hospitalization.

In this study, we included all inpatient admissions with discharges from January 1 to November 30 of each year for patients aged 1 to 17 years old. We excluded December discharges to allow for the full 30-day readmission window. Data on observation stays were not collected by the NRD. In-hospital deaths, patients who left against medical advice, and patients discharged to other acute care settings were similarly excluded. Infants <1 year of age were excluded because the majority of states in the NRD exclude these records.18 

For patient-level comparisons, we included all admissions for which the primary payer was Medicaid or a private insurer. Patients with dual eligibility were categorized under their primary payer. For hospital-level comparisons, only hospitals admitting a minimum of 30 Medicaid-insured and 30 privately insured pediatric patients were included to perform pair-wise comparisons of risk-adjusted readmission rates within hospitals.

Readmission was defined as any admission within 30 days of an index hospitalization. Hospitalizations after 30 days from discharge were evaluated as another index hospitalization. Patient-level readmission rates were calculated as the number of readmissions within 30 days over the total number of index hospitalizations.

Hospital-level 30-day readmission rates were calculated by using the Pediatric All-Condition Readmission Measure to adjust for differences in case-mix across hospitals.19,20  This measure excludes events for planned procedures and chemotherapy to identify only unplanned readmissions. This measure uses a hierarchical logistic regression model with a random hospital intercept that includes age, sex, the presence of 17 chronic condition body system indicators, and the number of body systems affected by chronic conditions to calculate 30-day risk-adjusted readmission rates for Medicaid- and privately insured patients separately. Thirty-day risk-adjusted readmission rates were calculated as the ratio of “predicted” number of readmissions (obtained from the model hospital-specific effect) to “expected” number of admissions (obtained from the model applying the average effect among hospitals) multiplied by the national observed readmission rate.

Index admission characteristics (age, sex, medical complexity, inpatient transfer rate, length of stay, hospital ownership, and hospital teaching status) were summarized and compared for Medicaid beneficiaries and privately insured patients in 2010 and 2017. Medical complexity was assessed by using the Pediatric Medical Complexity Algorithm.21  Hospitals in 2010 and 2017 were divided into tertiles based on the percentage of pediatric discharges covered by Medicaid and compared with examine trends in hospital characteristics. SAS version 9.4 (SAS Institute, Inc, Cary, NC) survey procedures were used to account for the complex sampling design and to weight observations to national estimates.

To assess trends in patient-level 30-day readmission rates by insurance provider, we plotted weighted unadjusted readmission rates for patients insured by Medicaid and private insurers from 2010 to 2017 and then compared these trends by using generalized linear models by using weighted counts and a Poisson link function. The log-transformed total admission-years was used as an offset in the model to obtain the expected number of 30-day readmissions. Multivariable analyses were repeated by using the same approach. Specifically, we calculated population-weighted 30-day readmission counts and total admission-years for 18 demographic categories (age [1–5, 6–12, and 13–17 years], sex, and medical complexity [nonchronic, chronic noncomplex, and chronic complex]) in Medicaid- and privately insured patients separately. We then fit a generalized linear model with a Poisson link function adjusting for age, sex, and medical complexity. Interaction terms between insurance and year were used to examine differences in readmission trends for Medicaid- and privately insured patients.

Trends in mean hospital 30-day risk-adjusted readmission rates were examined for Medicaid- and privately insured patients separately by using linear regression with only year in the model. Paired differences in 30-day risk-adjusted readmission rates for Medicaid and privately insured patients admitted to the same hospital were compared from 2010 to 2017 by using linear regression. Parameter estimates <0 indicate narrowing of the disparity in readmission rates by insurance, whereas parameter estimates >0 indicate widening of the disparity.

This analysis included between 433 062 and 527 958 index admissions annually, which were weighted to between 1.7 and 2.0 million pediatric admissions. The percentage of pediatric admissions insured by Medicaid ranged from 58.5% to 60.6% annually (Supplemental Table 4). On average, Medicaid beneficiaries were older than privately insured patients and were more likely to be admitted to public or for-profit hospitals across all years (Table 1). A higher percentage of Medicaid admissions were for patients with chronic or complex conditions in all years except 2010. Inpatient transfer rates were similar for Medicaid- and privately insured patients, but Medicaid beneficiaries had longer lengths of stay.

TABLE 1

Weighted Admission Characteristics for Pediatric Patients Insured by Medicaid and Private Insurers From 2010 to 2017

20102017
Medicaid (n = 1 223 028)Private Insurance (n = 802 243)PaMedicaid (n = 1 015 278)Private Insurance (n = 659 440)Pa
Age, y, mean (SE) 5.5 (0.4) 6.5 (0.4) .001 5.7 (0.2) 6.1 (0.2) .001 
Female sex, % (SE) 49.3 (0.5) 47.5 (0.3) <.001 49.0 (0.4) 47.6 (0.3) <.001 
PMCA chronic or complex conditions, % (SE)   .42   <.001 
 Nonchronic condition 80.3 (1.5) 80.8 (1.4)  78.2 (1.1) 80.0 (1.1)  
 Noncomplex chronic condition 5.2 (0.4) 4.8 (0.3)  5.1 (0.2) 4.3 (0.2)  
 Complex chronic condition 14.5 (1.3) 14.4 (1.3)  16.7 (1.1) 15.6 (1.0)  
Inpatient transfer, % (SE) 1.6 (0.3) 1.9 (0.5) .22 2.6 (0.3) 2.6 (0.3) .81 
Length of stay, d, mean (SE) 5.9 (0.4) 5.6 (0.3) .23 7.4 (0.2) 6.9 (0.2) .008 
Ownership, n (%)   <.001   <.001 
 Public 17.2 (3.5) 11.5 (2.3)  13.5 (2.3) 10.0 (2.5)  
 Nonprofit private 69.4 (4.3) 80.2 (3.0)  78.4 (2.6) 85.2 (2.6)  
 For-profit private 13.5 (3.2) 8.3 (1.7)  8.1 (1.2) 4.8 (0.8)  
Teaching status and location, n (%)   .094   .14 
 Metropolitan, nonteaching 27.2 (3.8) 25.4 (3.4)  12.1 (1.8) 12.2 (2.4)  
 Metropolitan, teaching 63.1 (3.9) 67.4 (3.7)  82.8 (2.0) 83.7 (2.5)  
 Nonmetropolitan 9.7 (1.0) 7.2 (1.0)  5.1 (0.5) 4.1 (0.5)  
20102017
Medicaid (n = 1 223 028)Private Insurance (n = 802 243)PaMedicaid (n = 1 015 278)Private Insurance (n = 659 440)Pa
Age, y, mean (SE) 5.5 (0.4) 6.5 (0.4) .001 5.7 (0.2) 6.1 (0.2) .001 
Female sex, % (SE) 49.3 (0.5) 47.5 (0.3) <.001 49.0 (0.4) 47.6 (0.3) <.001 
PMCA chronic or complex conditions, % (SE)   .42   <.001 
 Nonchronic condition 80.3 (1.5) 80.8 (1.4)  78.2 (1.1) 80.0 (1.1)  
 Noncomplex chronic condition 5.2 (0.4) 4.8 (0.3)  5.1 (0.2) 4.3 (0.2)  
 Complex chronic condition 14.5 (1.3) 14.4 (1.3)  16.7 (1.1) 15.6 (1.0)  
Inpatient transfer, % (SE) 1.6 (0.3) 1.9 (0.5) .22 2.6 (0.3) 2.6 (0.3) .81 
Length of stay, d, mean (SE) 5.9 (0.4) 5.6 (0.3) .23 7.4 (0.2) 6.9 (0.2) .008 
Ownership, n (%)   <.001   <.001 
 Public 17.2 (3.5) 11.5 (2.3)  13.5 (2.3) 10.0 (2.5)  
 Nonprofit private 69.4 (4.3) 80.2 (3.0)  78.4 (2.6) 85.2 (2.6)  
 For-profit private 13.5 (3.2) 8.3 (1.7)  8.1 (1.2) 4.8 (0.8)  
Teaching status and location, n (%)   .094   .14 
 Metropolitan, nonteaching 27.2 (3.8) 25.4 (3.4)  12.1 (1.8) 12.2 (2.4)  
 Metropolitan, teaching 63.1 (3.9) 67.4 (3.7)  82.8 (2.0) 83.7 (2.5)  
 Nonmetropolitan 9.7 (1.0) 7.2 (1.0)  5.1 (0.5) 4.1 (0.5)  

PMCA, Pediatric Medical Complexity Algorithm.

a

P value for χ2 tests for categorical variables and Student t tests for continuous variables.

Crude 30-day readmission rates were similar for Medicaid- and privately insured patients in 2010 (P = .90) but higher for Medicaid-insured patients in 2011 to 2017 (P < .05 all years) (Fig 1A). Over the study period, 30-day readmission rates for Medicaid beneficiaries decreased from 6.6% (SE 0.8%) in 2010 to 6.1% (SE 0.2%) in 2017, corresponding to a 0.5% (95% confidence interval [CI]: 0.4%–0.6%) reduction annually (rate ratio [RR]: 0.995; 95% CI: 0.994–0.996) (Table 2). Privately insured patients experienced a more rapid decline in 30-day readmission rates from 6.5% (SE 0.7%) in 2010 to 5.5% (SE 0.2%) in 2017, corresponding to a 1.2% (95% CI 1.1%–1.4%) reduction annually (RR: 0.988; 95% CI: 0.986–0.989]) (P for interaction <.001).

FIGURE 1

Readmission rates for Medicaid-insured versus privately insured pediatric patients from 2010 to 2017 calculated at the (A) patient and (B) hospital level.

FIGURE 1

Readmission rates for Medicaid-insured versus privately insured pediatric patients from 2010 to 2017 calculated at the (A) patient and (B) hospital level.

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TABLE 2

Unadjusted and Adjusted Analyses Comparing Trends in 30-Day Readmission Rates by Insurance Type From 2010 to 2017 at the Patient Level

UnadjustedAdjusted
Weighted Risk RatioPWeighted Risk RatioaP
Admission-level analyses     
 Privately insured 0.988 (0.986, 0.989) <.001 0.994 (0.992, 0.996) <.001 
 Medicaid-insured 0.995 (0.994, 0.996) <.001 0.994 (0.992, 0.995) <.001 
Hospital-level analyses   Slope (SE) P 
 Privately insured, % — — 0.018 (0.012) .14 
 Medicaid-insured, % — — 0.033 (0.014) .017 
 Pair-wise comparison, % — — 0.015 (0.011) .19 
UnadjustedAdjusted
Weighted Risk RatioPWeighted Risk RatioaP
Admission-level analyses     
 Privately insured 0.988 (0.986, 0.989) <.001 0.994 (0.992, 0.996) <.001 
 Medicaid-insured 0.995 (0.994, 0.996) <.001 0.994 (0.992, 0.995) <.001 
Hospital-level analyses   Slope (SE) P 
 Privately insured, % — — 0.018 (0.012) .14 
 Medicaid-insured, % — — 0.033 (0.014) .017 
 Pair-wise comparison, % — — 0.015 (0.011) .19 

—, not applicable.

a

Patient-level analyses are adjusted for patient age, sex, and the Pediatric Medical Complexity Algorithm.

After adjustment for age, sex, and the presence of a complex or chronic condition, readmission rates for Medicaid- and privately insured patients continued to decline (Medicaid RR: 0.994; 95% CI: 0.992–0.995, P < .001 versus private RR: 0.994; 95% CI: 0.992–0.996, P < .001); however, the rate of decline was similar for both groups (P for interaction = .87).

The greatest reduction in crude 30-day readmission rates occurred between 2010 and 2011. Therefore, we repeated the patient-level analyses excluding 2010 to determine if readmission rates declined during this period or remained stable. From 2011 to 2017, crude 30-day readmission rates increased by 1% annually (95% CI 0.8%–1.2%) for both Medicaid- and privately insured patients (P for interaction .22) (Supplemental Table 5). After adjustment, the trend became slightly negative for privately insured patients and stable for Medicaid-insured patients (P for interaction .087).

The number of hospitals included in our sample ranged from 414 to 506 annually (Supplemental Table 6). Approximately 70% to 76% of hospitals were excluded for insufficient numbers of both Medicaid- and privately insured pediatric patients, which accounted for 8.2% to 10.9% of pediatric patients annually. Hospitals included in the sample tended to be larger and were more likely to be nonprofit teaching hospitals (Supplemental Table 7). Across all years, hospitals with a high percentage of Medicaid beneficiaries were more likely to be owned by public or for-profit private corporations and were more likely to be large (Table 3). Hospital 30-day risk-adjusted readmission rates for Medicaid beneficiaries were higher than those for privately insured patients across all years (Fig 1B). Mean hospital 30-day risk-adjusted readmission rates increased slightly for Medicaid beneficiaries, from 6.5% (SD 2.1%) in 2010 to 6.9% (SD 1.8%) in 2017 (P = .017), but remained stable for privately insured patients, from 5.9% (SD 2.0%) in 2010 to 6.0% (SD 1.1%) in 2017 (P = .14). Likewise, paired differences in 30-day risk-adjusted readmission rates remained stable over time (P = .19; Fig 2, Table 2).

TABLE 3

Hospital Characteristics by Tertile of Percentage of Patients Insured by Medicaid in 2010 and 2017

Percentage of Pediatric Patients Insured by Medicaid in 2010, TertilePPercentage of Pediatric Patients Insured by Medicaid in 2017, TertileP
Low (n = 164)Medium (n = 168)High (n = 164)Low (n = 162)Medium (n = 151)High (n = 160)
Percent of pediatric discharges covered by Medicaid, median (IQR) 41.8 (29.5–47.9) 60.4 (55.9–64.7) 75.2 (71.2–81.1) <.001 43.5 (36.2–48.2) 61.6 (56.3–64.7) 76.7 (71.8–82.4) <.001 
Ownership, n (%)    <.001    <.001 
 Public 15 (9.2) 32 (19.1) 50 (30.5)  12 (7.4) 12 (8.0) 33 (20.6)  
 Nonprofit private 138 (84.2) 119 (70.8) 83 (50.6)  143 (88.3) 128 (84.8) 100 (62.5)  
 For-profit private 11 (6.7) 17 (10.1) 31 (18.9)  7 (4.3) 11 (7.3) 27 (16.9)  
Teaching status and location, n (%)    .61    .047 
 Metropolitan, nonteaching 70 (42.7) 69 (41.1) 58 (35.4)  38 (23.5) 29 (19.2) 24 (15.0)  
 Metropolitan, teaching 69 (42.1) 68 (40.5) 73 (44.5)  108 (66.7) 116 (76.8) 118 (73.8)  
 Nonmetropolitan 25 (15.2) 31 (18.5) 33 (20.1)  16 (9.9) 6 (4.0) 18 (11.3)  
No. pediatric discharges, n (%)    <.001    .001 
 Small (30–99) 17 (10.4) 24 (14.3) 0 (0)  17 (10.5) 9 (6.0) 0 (0)  
 Medium (100–999) 122 (74.4) 111 (66.1) 134 (81.7)  119 (73.5) 107 (70.9) 127 (79.4)  
 Large (>1000) 25 (15.2) 33 (19.6) 30 (18.3)  26 (16.1) 35 (23.2) 33 (20.6)  
Percentage of Pediatric Patients Insured by Medicaid in 2010, TertilePPercentage of Pediatric Patients Insured by Medicaid in 2017, TertileP
Low (n = 164)Medium (n = 168)High (n = 164)Low (n = 162)Medium (n = 151)High (n = 160)
Percent of pediatric discharges covered by Medicaid, median (IQR) 41.8 (29.5–47.9) 60.4 (55.9–64.7) 75.2 (71.2–81.1) <.001 43.5 (36.2–48.2) 61.6 (56.3–64.7) 76.7 (71.8–82.4) <.001 
Ownership, n (%)    <.001    <.001 
 Public 15 (9.2) 32 (19.1) 50 (30.5)  12 (7.4) 12 (8.0) 33 (20.6)  
 Nonprofit private 138 (84.2) 119 (70.8) 83 (50.6)  143 (88.3) 128 (84.8) 100 (62.5)  
 For-profit private 11 (6.7) 17 (10.1) 31 (18.9)  7 (4.3) 11 (7.3) 27 (16.9)  
Teaching status and location, n (%)    .61    .047 
 Metropolitan, nonteaching 70 (42.7) 69 (41.1) 58 (35.4)  38 (23.5) 29 (19.2) 24 (15.0)  
 Metropolitan, teaching 69 (42.1) 68 (40.5) 73 (44.5)  108 (66.7) 116 (76.8) 118 (73.8)  
 Nonmetropolitan 25 (15.2) 31 (18.5) 33 (20.1)  16 (9.9) 6 (4.0) 18 (11.3)  
No. pediatric discharges, n (%)    <.001    .001 
 Small (30–99) 17 (10.4) 24 (14.3) 0 (0)  17 (10.5) 9 (6.0) 0 (0)  
 Medium (100–999) 122 (74.4) 111 (66.1) 134 (81.7)  119 (73.5) 107 (70.9) 127 (79.4)  
 Large (>1000) 25 (15.2) 33 (19.6) 30 (18.3)  26 (16.1) 35 (23.2) 33 (20.6)  

IQR, interquartile range.

FIGURE 2

Paired differences in Medicaid versus private insurance hospital risk-standardized readmission rates by year from 2010 to 2017.

FIGURE 2

Paired differences in Medicaid versus private insurance hospital risk-standardized readmission rates by year from 2010 to 2017.

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Using a nationally representative sample of US pediatric hospitalizations, we found that Medicaid beneficiaries had higher rates of 30-day readmission than privately insured patients from 2011 to 2017. Rates of readmission for privately insured patients declined from 2010 to 2017, whereas rates of readmission for Medicaid-insured patients declined from 2010 to 2011 and then remained stable from 2011 to 2017. After the initial decline in readmission rates for both Medicaid- and privately insured patients from 2010 to 2011, the gap in readmission rates by insurance persisted from 2011 to 2017. Hospital 30-day risk-adjusted readmission rates increased slightly for Medicaid-insured patients but remained stable for privately insured patients as did the gap in readmission rates by insurance. These observations suggest that despite fluctuations in readmission rates for both Medicaid and privately insured patients, the disparity by insurance status persists.

Several studies have documented a higher rate of readmission for children insured by Medicaid compared with those insured by private companies.1113  Barrett et al13  compared crude readmission rates for patients aged 1 to 20 years in 2009 and 2013 using the Healthcare Cost and Utilization Project NRD. In both years, rates of readmission among Medicaid beneficiaries were higher than those among privately insured patients. Similarly, Berry et al11  reported higher unadjusted and adjusted rates of readmission for pediatric patients with public insurance relative to those with private insurance using data from the 2009–2010 National Association of Children’s Hospitals and Related Institutions.

We found a decline in 30-day readmission rates for Medicaid-insured patients from 2010 to 2011, which then stabilized from 2011 to 2017. Passage of the Affordable Care Act, expansion of Medicaid coverage, and an increased emphasis on delivery system reforms to constrain costs and improve quality may explain some of the reduction in readmission rates for both Medicaid- and privately insured patients from 2010 to 2011; however, these reductions were not borne out in subsequent years. Another possible explanation is the implementation of the Hospital Readmissions Reduction Program (HRRP); however, this seems unlikely. The HRRP was established in 2010 but did not go into effect until 2013 and only applied to adult hospitals serving Medicare beneficiaries. Although many hospitals began to prioritize readmission reduction efforts as soon as the Program was implemented, data from other studies suggest that Medicare readmissions did not start to decline until 2012.22 

Conversely, we found that hospital-level risk-adjusted readmission rates increased for Medicaid-insured patients and remained stable for privately insured patients. Differences in trends at the patient-level and hospital-level are likely explained by differences in inclusion criteria and clustering of patients within hospitals. First, the patient-level analyses included all pediatric patients insured by both Medicaid or private insurers, whereas the hospital-level analyses included only those patients admitted to hospitals with adequate volume for risk adjustment (∼24%–30% of all hospitals admitting pediatric patients). Second, in patient-level analyses, absolute rates over time were examined, whereas in hospital-level analyses, mean readmission rates across hospitals were examined, with all hospitals weighted equally. Third, the hospital-level analyses accounted for clustering of patients in the models, and thus large-volume hospitals do not contribute as much to the hospital-level estimates as the individual patients in these hospitals do to the patient-level estimates.

To our knowledge, this is the first study in which trends in readmission disparities over time are examined in a pediatric population. Ferro et al23  evaluated trends in readmission rates for conditions targeted by the Centers for Medicare and Medicaid Services HRRP among patients insured by Medicare, Medicaid, and private insurers. They found that the HRRP was associated with a significant decline in readmissions for Medicare and Medicaid beneficiaries, but readmission rates for privately insured patients increased after its implementation. Despite these trends, readmissions for Medicaid beneficiaries remained significantly higher than those for Medicare- or privately insured patients. Researchers of other studies in adult populations have reported mixed results for racial and socioeconomic disparities in readmission rates over time.2427 

Over half of pediatric admissions in the United States are covered by Medicaid, and this number has grown substantially under the Affordable Care Act and the Children’s Health Insurance Program.16,17  As such, this population represents an important target for readmission reduction efforts with the potential to significantly cut health care expenditures. In 2014, federal spending on pediatric Medicaid beneficiaries neared $90 billion, and inpatient care accounted for ∼30% of these expenditures.28,29  Although data regarding total Medicaid expenditures on pediatric readmissions are not readily available, readmissions for Medicaid beneficiaries cost ∼$1000 more on average than those for privately insured patients, and episodes of care that result in readmissions are 2.3 times more expensive than those without readmissions.13,30 

There are several potential explanations for the higher readmission rates observed in Medicaid-insured patients who may shed light on strategies for eliminating this disparity. Consistent with previous studies, we found that patients insured by Medicaid had more chronic or complex conditions than those insured by private insurers. Because children with medical complexity account for only ∼6% of all children covered by Medicaid but 71% of readmissions and 34% of pediatric Medicaid expenditures,31,32  many have argued for focusing cost-saving efforts on this population. Multiple interventions to prevent readmissions in children with medical complexity (eg, discharge bundles, intensive follow-up, and education interventions) have been implemented with varied success.7,33,34  Previous research has revealed that these patients are not only at higher risk of readmission than children without chronic conditions, but they also remain at increased risk of readmission over a longer time.12  As such, multicomponent discharge bundles appear necessary to address the many stages of transitioning from hospital to home. These interventions may decrease overall pediatric readmissions by targeting patients with medical complexity; however, they are unlikely to alter the disparity in readmission rates by insurance type. The percentage of patients with medical complexity differed by only 1% to 2% annually for patients insured by Medicaid and private insurers. These findings suggest that differences in medical complexity do not solely account for the higher rates of readmission observed in Medicaid beneficiaries.

Another explanation for these findings relates to differences in socioeconomic status between Medicaid- and privately insured patients. Patients insured by Medicaid may experience more social and economic challenges that affect their health and ability to obtain needed care.35  Interruptions in coverage, low literacy, language barriers, lack of transportation, unstable housing, poverty, food insecurity, and inability to afford medications or copays may contribute to the higher risk of readmission.3638  In addition, these patients and their families may be less familiar with navigating the health care system or accessing follow-up care. Children insured by Medicaid are less likely to have a usual source of care or medical home to help maintain their health after hospital discharge.39,40 

Innovative care models such as patient-centered medical homes and accountable care organizations may be one strategy for reducing readmissions in Medicaid patients with high resource use.41,42  Partnering with teams of providers, these organizations strive to provide comprehensive care in both the inpatient and outpatient settings to ensure easier access to care for patients and their families. Extending these resources to community supports such as transportation services, food subsidy programs, health literacy training, and housing referrals may be helpful to address other environmental determinants of health outcomes given the socioeconomic divide by insurance.

This study should be considered in light of its limitations. First, we did not have data on observation stays or emergency visits. Previous studies in adult populations have reported differences in the use of observation stays by payer; however, the differences are frequently small when similar populations are compared.43,44  Moreover, data from Medicare populations suggest that hospitals are not using observation stays to reduce their inpatient readmission rates despite readmission penalties implemented by Centers for Medicare and Medicaid Services.4547  Thus, it seems unlikely that pediatric providers would be using this strategy to reduce readmission rates. Therefore, we expect that the inclusion of observation stays in our analysis might increase the total number of hospitalizations but should not impact the overall findings. Second, we classified admissions by primary payer only and were unable to distinguish admissions for patients with dual coverage. Third, we were unable to identify out-of-state readmissions and out-of-hospital deaths, but we expect both numbers to be low in pediatric patients. Fourth, we excluded a substantial number of hospitals for the hospital-level analyses to generate stable risk-adjusted readmission estimates. These exclusions accounted for a relatively small percentage of pediatric patients overall because most hospitals in the NRD served only a few pediatric patients annually. As a result, our results may not be generalizable to all hospitals or the entire pediatric population. Finally, adjustment for patient age, sex, and medical complexity may have been insufficient to remove the differences in readmission rates by insurance status. Residual confounding by other patient factors such as specific comorbidities or socioeconomic status is possible.

In summary, we found that after accounting for changes in patient medical complexity, 30-day readmission rates are declining for both Medicaid- and privately insured pediatric patients but remain substantially higher among Medicaid beneficiaries. These trends were not explained by differences in patient demographics or medical complexity across insurance groups. Future studies are needed to evaluate the extent to which readmissions in the Medicaid population are preventable and to identify strategies to reduce readmissions in this group.

Dr Bucholz obtained the data, performed and interpreted the data analyses, and drafted and revised the manuscript; Drs Schuster and Toomey interpreted the data analyses and revised the manuscript; and all authors conceptualized and designed the study.

FUNDING: Drs Schuster and Toomey are supported by the US Department of Health and Human Services Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services, CHIPRA Pediatric Quality Measures Program Centers of Excellence under grant U18 HS 020513 (principal investigator: Dr Schuster) and U18 HS 025299 (principal investigator: Dr Toomey). The content is solely the responsibility of the authors and does not represent the official views of the Agency for Healthcare Research and Quality.

     
  • CI

    confidence interval

  •  
  • HRRP

    Hospital Readmissions Reduction Program

  •  
  • NRD

    Nationwide Readmissions Database

  •  
  • RR

    rate ratio

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data