Abstract A122: Payer-Based Disparities in Post-Acute Stroke Care: An Analysis of Discharge Patterns for Medicare Advantage vs. Traditional Medicare Beneficiaries

Introduction: Acute ischemic stroke is a leading cause of long-term disability. A national American Heart Association guideline recommends high-quality post-acute inpatient rehabilitation to optimize recovery. Post-acute care can occur in an inpatient rehabilitation facility (IRF), which offers intensive, multidisciplinary therapy, or a skilled nursing facility (SNF) with less intensive less organized care. Differences in access may lead to significant disparities in outcomes. There has been explosive growth in Medicare Advantage (MA). Private insurers like MA receive fixed payments to manage patient care and population risk, creating a financial incentive to control costs vs Traditional Medicare (TM). This may influence post-acute discharge destination. Hypothesis: A SNF stay is less expensive than an IRF stay. Hence, it was hypothesized that MA would preferentially discharge to SNF. Methods: We investigated the association between Medicare payer type and discharge disposition in the AHA Get With The Guidelines-Stroke registry. The sample was Medicare beneficiaries aged 65+ with ischemic stroke 2020-2024. A linear regression model was used to analyze discharge location (IRF vs SNF) stratified by payer (TM vs MA), adjusted for relevant covariates on the AHA’s Precision Medicine Platform. Results: The study population was 286,772: 44.9% enrolled in TM and 55.1% in MA. A significant disparity in discharge location was observed. For TM, 55.4% were discharged to IRF and 44.6% to SNF. In contrast, for MA, 51.2% were discharged to IRF and 48.8% to SNF. After adjusting for multiple clinical and non-clinical confounders, MA remained independently associated with a significantly lower likelihood of discharge to IRF compared to TM. The probability of discharge to IRF (vs SNF) was -4.22 percentage points lower for MA (vs TM) (95% CI, -3.72 - -4.72 pps; p<0.001). Conclusions: MA beneficiaries with ischemic stroke were signficantly more likely to be discharged to SNF vs those with TM, indicating that program models related to payment mechanism and financial incentives may be associated with discharge disposition. This study is the first to report a discharge location disparity for ischemic stroke among Medicare beneficiaries by payer type. The study is observational; however, because the results could have significant policy implications, a randomized controlled trial of post-stroke discharge location among Medicare beneficiaries is warranted to confirm these findings.