Study Reveals Downside of Medicare Advantage Plans for Stroke Patients

Medicare Advantage plans have many appeals compared to Original Medicare as they tend to offer more benefits and coverage. But those programs may not be all they’re cracked up to be when it comes to stroke patients.

A recent study suggests that stroke patients enrolled in Medicare Advantage plans may receive lower-quality postnatal care than those with Original Medicare. That gap appears to be widening for Medicaid-eligible patients.

The study, published in JAMA Network Open, analyzed national data from 44,000 Medicare beneficiaries age 65 and older who were hospitalized for stroke.

The researchers examined patients treated in inpatient rehabilitation facilities, skilled nursing facilities or home health facilities. They rated quality using a five-star rating system from the Centers for Medicare and Medicaid Services (CMS).

Medicare Advantage versus Original Medicare

Medicare Advantage is one of the two main types of Medicare. Another is Original Medicare, also known as traditional Medicare.

Original Medicare is offered directly by the state government, while private insurers that contract with the government offer Medicare Advantage plans.

Medicare Advantage plans must cover the same services as those covered by Original Medicare but may also cover other costs. Therefore, Medicare Advantage plans can vary greatly when it comes to coverage and costs – as well as customer satisfaction.

Medicaid is a joint federal and state program that provides health care for low-income people.

The difference in care

A stroke can significantly change a person’s cognitive and physical abilities. That’s why quality rehab care is so important – both for stroke recovery and stroke risk reduction.

Amol Karmarkar, a professor in the VCU School of Medicine’s Department of Physical Medicine and Rehabilitation and one of the study’s lead researchers, summarizes the findings:

“Access to high-quality post-acute care is critical to restoring function and good health outcomes for stroke patients, so they can return to health and their communities.”

According to the study, among patients who were ineligible for Medicaid, those with Medicare Advantage plans were less likely to receive care in more limited settings than Original Medicare enrollees:

• Skilled nursing facilities: 53% of Medicare Advantage patients went to very limited facilities, compared to 58% with Original Medicare
• Home health centers: 19% of Medicare Advantage patients used agencies with higher rates, compared to 22% for Original Medicare

The difference was most notable among “dual eligible” patients (those on both Medicare and Medicaid), who tend to have higher stroke severity and greater health care needs. Here’s what research at skilled nursing facilities found:

• Only 42% of eligible dual Medicare Advantage patients received very limited care
• Only 44% of dual-eligible Original Medicare patients received very limited care

The researchers found no statistical difference in the quality of care for patients discharged from inpatient rehabilitation facilities.

What causes the gap?

Researchers point to several possible factors. Medicare Advantage plans often use smaller provider networks to keep costs down, which may limit patient access to more limited areas. Geography may play a role if high-quality facilities are far from where patients live.

Another problem is that many patients, caregivers and providers are not familiar with CMS quality measurement tools.

“[U]understanding these publicly available rating systems is important because the quality of post-hospital care services may impact the patient’s short-term experience and long-term recovery patterns,” notes Karmarkar.

The big picture for Medicare enrollees

Medicare Advantage plans now cover more than half of all eligible Medicare beneficiaries. About 35.5 million people were registered as of Feb. 1. These plans tend to appeal to seniors with lower premiums, reduced copays and additional benefits.

Unlike Original Medicare, however, they often require prior authorization for services and limit enrollees to certain networks of doctors, hospitals and rehab centers.

For anyone weighing Medicare options, especially those with medical conditions that may increase the risk of stroke, this study suggests it’s worth investigating what falls within the plan’s network before enrolling.

Taking the time to check the quality ratings of in-network locations now can make a big difference in your recovery options in the long run.

Read more about what to expect from Medicare coverage in “Retirees, Beware: Medicare Won’t Cover These 11 Medical Expenses” and “Many People in Medicare Advantage Are Losing Out Because of This Mistake.”