Medicare Advantage and Medicare-Medicaid eligible patients less likely to use highly rated stroke rehabilitation, new study finds

By Olivia Trani

Stroke patients with Medicare Advantage health insurance plans are less likely to be discharged to highly rated post-acute care than those covered by traditional Medicare, according to a new study co-led by researchers at Virginia Commonwealth University. The results, published this week in JAMA Network Open, also show these disparities were most pronounced among patients dually eligible for both Medicare and Medicaid.

“Having access to high-quality post-acute care is vital for functional recovery and positive health outcomes for stroke patients, so that they can return to their lives and communities,” said Amol Karmarkar, Ph.D., a professor in VCU School of Medicine’s Department of Physical Medicine and Rehabilitation and Center for Rehabilitation Science and Engineering and one of the lead researchers on this study. He is also the director of research at the Sheltering Arms Institute, a rehabilitation facility in Richmond in collaboration with VCU Health. “Our findings reveal concerning differences in patient experiences with post-acute care, which may further worsen disparities in stroke recovery and long-term health outcomes.”

A stroke can dramatically impact a person’s cognitive and physical abilities, and patients often require post-acute rehabilitative care to help their recovery, regain independence and reduce the risk of another stroke. Post-acute care for stroke is typically provided through inpatient rehabilitation facilities, skilled nursing facilities or home health services, but a patient’s access to high-quality facilities can differ depending on their insurance coverage.

Medicare Advantage – a private alternative to the federally funded Medicare program for seniors – has become an increasingly popular type of health insurance. As of Feb. 1, nearly 35.5 million people have enrolled in Medicare Advantage plans, accounting for more than 50% of all Medicare-eligible beneficiaries.

These plans often advertise extra benefits and lower premiums and co-pays, making them an attractive option for beneficiaries. However, unlike traditional Medicare plans, Medicare Advantage plans often require prior approval for health services and have network restrictions that could prevent enrollees from being seen by certain doctors, hospitals and rehabilitative facilities.

For the new study, Karmarkar and a multi-institutional team of researchers aimed to better understand whether stroke patients with Medicare Advantage plans versus traditional Medicare plans have different post-acute care experiences. The team also assessed how these plans impact the quality of care for patients who qualify for both Medicare and Medicaid, which offers coverage for lower-income Americans. Access to rehabilitative services is particularly important for this dual-eligible population since participants are more likely to experience higher stroke severity and have more health care needs. 

With funding support from the National Institutes of Health, the researchers analyzed national data from more than 44,000 Medicare beneficiaries, ages 65 or older, who were hospitalized for stroke between 2021 and 2022. They specifically looked at data from patients who received care from inpatient rehabilitation facilities, skilled nursing facilities or home health agencies following hospitalization.

They measured the quality of post-acute care using the Centers for Medicare & Medicaid Services’ 5-star rating systems for skilled nursing facilities and home health agencies. These ratings are influenced by a number of factors, including health inspections, adequate staffing levels and patient health outcomes. (Because CMS does not provide a rating system for inpatient rehabilitation facilities, the researchers instead looked at the rate of potentially preventable hospital readmissions from these facilities, which is a quality measure used by CMS.)

Their analysis revealed the following:

• Among non-dual-eligible patients, those enrolled in Medicare Advantage plans were less likely than those in traditional Medicare plans to receive post-acute care from highly rated skilled nursing facilities (53.2% vs. 58%) and home health agencies (18.6% vs. 21.9%).
• Dual-eligible patients were even less likely to receive care at highly rated skilled nursing facilities, regardless of whether they were enrolled in Medicare Advantage plans (41.7%) or traditional Medicare (43.8%).
• There was no statistical difference in the quality of care for patients discharged to inpatient rehabilitation facilities.

While more research is needed, the study authors say a few factors may be driving these disparities. For example, while narrow provider networks in Medicare Advantage plans may help keep costs low and improve efficiency, they could also limit patient access to more highly rated facilities. Geography may be another factor for patients, especially if higher-rated facilities are farther away. The researchers also noted that a lack of awareness of the quality rating systems for post-acute care could be influencing these disparities.

“When it comes to selecting post-acute care options, patients, caregivers and providers aren’t always aware that these tools exist to help make informed decisions,” Karmarkar said. “However, understanding these publicly available rating systems are critical because the quality of post-acute care services may ultimately influence a patient’s short-term experience and long-term recovery patterns.”

The researchers are conducting further studies to examine how disparities in access to highly rated facilities and services affect recovery and long-term health outcomes for stroke survivors.