Challenges in Accessing Quality Postacute Care for Elderly Patients
A recent study published in JAMA Network Open underscores the challenges elderly patients face in accessing high-quality postacute care after hospitalization for acute ischemic stroke. This is especially true for those enrolled in Medicare Advantage (MA) plans or who are dual-eligible for Medicare and Medicaid. Research indicates that dual-eligible beneficiaries on Medicare fee-for-service (FFS) plans are less likely to be discharged to top-tier skilled nursing facilities compared to their non-dual-eligible counterparts on FFS plans. Similarly, MA plan patients, regardless of dual eligibility, face hurdles in accessing premium postacute care services.
Lead author Amol Karmarkar, PhD, from Virginia Commonwealth University, notes that MA plans often have limited networks, potentially restricting patient choices to lower-rated facilities. This limitation, along with pre-authorization requirements, could contribute to fewer approvals for premium postacute care, notably in inpatient rehabilitation settings. Regional availability of top-rated facilities also significantly influences the quality of care received, according to the study.
The analysis was conducted on a 20% sample of Medicare claims data from 44,078 patients aged 65 and older, who were hospitalized for stroke between January 2021 and September 2022. Researchers categorized these patients into four groups based on Medicare plan and dual-eligibility status. Within this cohort, 39.4% were discharged to rehabilitation facilities, 36.9% to skilled nursing facilities, and 23.8% received home health services. The quality of care was assessed using CMS's 5-star ratings and rates of preventable hospital readmissions during rehabilitation.
After adjusting for various factors, researchers found no significant differences in discharges to high-quality inpatient rehabilitation facilities among the groups. However, patients in MA or dual-eligible categories had reduced chances of being placed in high-quality skilled nursing facilities compared to those with standard FFS plans without dual eligibility. Discharge to home health services was negatively affected in regions with a higher concentration of skilled nursing facilities, while having more MA plans in a region increased the odds of placement in high-quality skilled nursing facilities.
Karmarkar and colleagues highlight the importance of raising awareness about care facility quality. They suggest that integrating high-quality options within MA plan networks may help bridge existing disparities. Future research will focus on clinical outcomes related to these observed differences and the decision-making processes involved in choosing postacute care facilities.