Medicare Type, Dual Eligibility Influence Quality of Postacute Stroke Care

Following hospitalization for acute ischemic stroke, older adults who are covered by Medicare Advantage (MA) plans and/or are dual-eligible beneficiaries enrolled in both Medicare and Medicaid are less likely to access high-quality postacute care, researchers show.

Compared with those on Medicare fee-for-service (FFS) plans who were not dual eligible, dual-eligible patients on FFS plans had lower odds of discharge to a high-quality skilled nursing facility. Also at a disadvantage were patients on MA plans, regardless of dual-eligibility status, according to lead author Amol Karmarkar, PhD (Virginia Commonwealth University, Richmond), and colleagues.

Among patients who were not dual eligible, those on an MA versus a FFS plan were less likely to receive postacute care from a high-quality home health agency (OR 0.71; 95% CI 0.62-0.82).

The disparities observed here could be related to the practice of MA plans working with narrow networks of facilities, Karmarkar told TCTMD. “Medicare Advantage typically doesn’t allow you to pick and choose any provider of your choice. They say these are the four providers or these are the four facilities that you can go to,” he said, adding that sometimes those facilities all will have low ratings.

Also playing into the differences between groups could be the MA pre-authorization process. “Obviously there is just a lot of denial for postacute care, especially [for] inpatient rehabilitation facilities,” Karmarkar said.

And finally, where a patient lives may influence their likelihood of having access to high-quality care, he noted. “Just the availability of the high-rated facilities in the area that you live in, or I should say a lack of availability, can also be one of . . . the reasons why some of these individuals go to lower-rated facilities.”

The study, published online last week in JAMA Network Open, “suggests that dual-eligible and MA beneficiaries with stroke experience disparities in receiving high-quality postacute care; improving awareness of postacute care facility quality ratings among patients, caregivers, and discharge planners, along with having high-quality facilities in the MA plan network, can help reduce these disparities,” Karmarkar et al write.

They note that “MA plans may be incentivized to reduce costs by using skilled nursing facilities that save money, even if those facilities deliver lower-quality care. With the concurrent growth of MA and dual enrollment, the design of value-based postacute care for these populations is a priority to ensure they maximize gains from postacute care services provision and achieve optimal health outcomes.”

Tracking Quality

This retrospective analysis was based on a 20% random sample of patient-level Medicare claims data on 44,078 beneficiaries 65 and older (mean age 79 years; 58% women) who were hospitalized for acute ischemic stroke between January 2021 and September 2022. The researchers divided the cohort into four mutually exclusive groups based on type of Medicare plan and dual-eligibility status:

• Non-dual eligible on an FFS plan (46.5%)
• Non-dual eligible on an MA plan (34.9%)
• Dual eligible on an MA plan (14.0%)
• Dual eligible on an FFS plan (11.9%)

Overall, 39.4% of patients were discharged to an inpatient rehabilitation facility, 36.9% to a skilled nursing facility, and 23.8% to a home health service. Postacute care quality was evaluated using the Centers for Medicare & Medicaid Services’ 5-star rating systems for skilled nursing facilities and home health agencies (a score of 4 or higher was considered high quality) and using the rate of potentially preventable hospital readmissions during an inpatient rehabilitation facility stay (at the national mean or lower was considered high quality).

After adjustment for individual-, hospital-, and hospital referral region-level factors, there were no differences across the four groups in the odds of being discharged to high-quality inpatient rehabilitation facilities.

Compared with patients on an FFS plan who were not dual eligible, however, those in the other three groups were less likely to be discharged to a high-quality skilled nursing facility:

• Non-dual eligible on an MA plan (OR 0.82; 95% CI 0.74-0.91)
• Dual eligible on an FFS plan (OR 0.57; 95% CI 0.50-0.65)
• Dual eligible on an MA plan (OR 0.56; 95% CI 0.50-0.64)

In addition, patients in hospital referral regions with a greater concentration of skilled nursing facilities were less likely to receive high-quality home health services (OR 0.56; 95% CI 0.35-0.88) and those in regions with a greater number of available MA plans were more likely to be discharged to a high-quality skilled nursing facility (OR 1.45; 95% CI 1.17-1.81).

“These differences in quality of skilled nursing facility care can be associated with health outcomes during the initial phases of stroke, particularly functional recovery, and prevention of infections, pressure ulcers, and hospital readmissions,” Karmarkar et al write.

Subsequent studies, Karmarkar said, will examine potential impacts on short- and long-term clinical outcomes based on the differences observed here and dig into how patients, caregivers, physicians, and discharge planners are deciding on which postacute care facilities to use.