Change Over Time in Hospital Care for Medicaid Beneficiaries: Analysis of Hospitalizations From 2016-2019

Historically, access to high-quality care has been a central challenge for Medicaid programs. Prior single-year analyses demonstrated that Medicaid beneficiaries account for disproportionately high patient volumes at low-quality hospitals. Given major Medicaid shifts including expansion and increased managed care, we examined recent trends in low-quality hospital use for Medicaid beneficiaries.

Using Healthcare Cost and Utilization Project State Inpatient Databases, we compiled adult hospital discharges from 15 states in years 2016-2019 (N=32,788,446). Hospital quality was assessed with the Agency for Healthcare Research and Quality (AHRQ) Composite Inpatient Quality Indicator, reflecting risk-adjusted mortality for prevalent conditions. We constructed a logistic regression modeling odds of discharge from a low-quality hospital (bottom 20 th percentile by year), with payer-year interactions and covariates for patient demographics (sex, age, race/ethnicity, income), comorbidities, state, and hospitalization type.

Overall, patients with Medicaid [adjusted odds ratio (aOR)=1.11, P <0.01] or Medicare (aOR=1.03, P <0.01) were more likely to be hospitalized in low-quality hospitals, compared with private insurance (reference). The likelihood of admission to low-quality hospitals over time varied by payer. Patients insured by Medicaid were 2% less likely to be admitted to low-quality hospitals each additional year (aOR=0.98, P <0.01). Medicare-insured patients did not show significant changes longitudinally, and privately insured patients were 3% more likely to be admitted to low-quality hospitals each year (aOR=1.03, P <0.01).

This is one of the first studies examining associations between payer and inpatient care quality over time, critical for our rapidly changing payment environment. Although Medicaid-insured patients remain more likely to be discharged from low-quality hospitals as compared with other payers, we find promising recent trends of improving hospital quality over time for Medicaid beneficiaries.