Understanding Patient, Provider, and System Factors Related to Medicaid Readmissions

Jt Comm J Qual Patient Saf. 2016 Mar;42(3):115-21. doi: 10.1016/s1553-7250(16)42014-3.


Background: Efforts on reducing hospital readmissions, which are intended to improve quality and reduce costs, tend to focus on elderly Medicare beneficiaries without recognition of another high-risk population--adult nonmaternal Medicaid patients. This study was undertaken to understand the complexity of Medicaid readmission issues at the patient, provider, and system levels.

Methods: Multiple qualitative methods, including site visits to nine safety-net hospitals, patient/family/caregiver inter views, and semistructured interviews with health plans and state Medicaid agencies, were used in 2012 and 2013 to obtain information on patient, provider, and system issues related to Medicaid readmissions; strategies considered or currently used to address those issues; and any perceived financial, regulatory or, other policy factors inhibiting or facilitating readmission reduction efforts.

Results: Significant risk factors for Medicaid readmissions included financial stress, high prevalence of mental health and substance abuse disorders, medication nonadherence, and housing instability. Lacking awareness on Medicaid patients' high risk, a sufficient business case, and proven strategies for reducing readmissions were primary barriers for providers. Major hurdles at the system level included shortage of primary care and mental health providers, lack of coordination among providers, lack of partnerships between health plans and providers, and limited data capacity for realtime monitoring of readmissions.

Conclusions: The intertwining of behavioral, socioeconomic, and health factors; the difficulty of accessing appropriate care in the outpatient setting; the lack of clear financial incentives for health care providers to reduce readmissions; and the fragmentation of the current health care system warrant greater attention and more concerted efforts from all stakeholders to reduce Medicaid readmissions.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Continuity of Patient Care / organization & administration
  • Health Services Accessibility / statistics & numerical data*
  • Housing / statistics & numerical data
  • Humans
  • Medicaid / statistics & numerical data*
  • Medication Adherence
  • Mental Disorders / epidemiology*
  • Patient Readmission / statistics & numerical data*
  • Poverty / statistics & numerical data*
  • Risk Factors
  • Social Work / organization & administration
  • Socioeconomic Factors
  • Substance-Related Disorders / epidemiology
  • United States