Abstract T P117: Impact of Medicaid Coverage on Utilization of Inpatient Rehabilitation Facilities

Abstract

Objective: Optimal post-acute care is associated with improved stroke outcomes. Among working age stroke patients discharged to institutional post-acute care, those with Medicaid are less likely to be discharged to an inpatient rehabilitation facility (IRF) than those with private insurance, a finding which may be influenced by state Medicaid coverage. We hypothesized that stroke patients residing in states where Medicaid does not cover IRFs would be less likely to be discharged to an IRF than patients residing in states where Medicaid covers IRFs. Methods: Working age ischemic stroke patients with Medicaid were identified from the 2010 Nationwide Inpatient Sample (NIS) using ICD-9 CM codes 433.x1, 434.x1 and 436. Medicaid coverage of IRFs (yes versus no) was ascertained for 45 states with NIS data by review of state Medicaid websites. The primary outcome was discharge to IRF (versus other discharge destinations). We fit a hierarchical logistic regression model that included patient-level factors (demographics and stroke severity measures (length of stay, t-PA use and Charlson comorbidity score)), and a state policy variable representing whether a State’s Medicaid pays for IRF, with a random intercept for hospital. Based on this model, we estimated the probability of utilization of IRFs in states with Medicaid coverage of IRFs compared to those without. Results: Medicaid did not cover IRFs in 4 (TN, TX, SC, WV) out of 45 states. Compared to stroke patients residing in states with Medicaid coverage of IRF, stroke patients hospitalized in states without Medicaid coverage of IRF were less likely to be discharged to an IRF (12.8% (7.5-18.0%) vs. 19.4% (17.0-21.8%), p=0.02) after adjusting for patient and hospital factors. Conclusion: Working age stroke patients with Medicaid who reside in states where Medicaid does not cover IRFs have less utilization of IRFs than patients residing in states where Medicaid covers IRFs. As the Medicaid population expands under the Patient Protection and Affordable Care Act and the number of working age stroke patients increase, careful attention to state Medicaid policy for post-acute care and analysis of its effects are warranted.