Ali Saad, MD

Skolarus LE, Burke JF, Morgenstern LB, Meurer WJ, Adelman EE, Kerber, et al. Impact of State Medicaid Coverage on Utilization of Inpatient  
Rehabilitation Facilities Among Patients With Stroke. Stroke. 2014

It may if you’re on Medicaid. This study suggests that residence plays an unfortunate role in a patient’s post stroke care. The authors examined 20,392 patients from the 2010 NIS (Nationwide Inpatient Sample) and followed whether they were discharged to IRFs (inpatient rehab facilities) versus other discharge destinations. All patients had Medicaid as their primary insurance and were of working age (18-64).

Of the 42 states analyzed, Medicaid did not cover IRFs in 4 states: TN, TX, SC, and WV. Having a stroke in one of these non-Medicaid IRF states conferred a 41% chance of not being discharged to an IRF compared to Medicaid-IRF states. No state-specific difference was found in non-Medicaid patients. It is especially concerning that this phenomenon is taking place in the “stroke belt”, which has a higher prevalence of stroke compared to the rest of the country.

The authors note that the accuracy of whether patients qualified for IRF is based on information from state-specific Medicaid websites. Nevertheless, a significant disparity remains. An important implication of this study is worsening health care disparity among working age minorities, although race/ethnicity was not available in the NIS database. Other factors including proximity of IRFs and patient preferences were not available in the NIS database.

Possible follow up studies include analyzing data from random hospitals in Medicaid-IRF versus non-Medicaid IRF states as the hospitals may have more patient demographic information than the NIS.

We have known for years that minority groups are at greater risk for the complications of stroke. Now stroke in the young is on the rise. Medicaid-IRF coverage requires further investigation to determine whether there is another target for improving health care disparities.