Medicare Advantage plans have a lot of appeal compared to Original Medicare since they tend to offer more perks and coverage. But those plans may not be all they’re cracked up to be when it comes to patients recovering from stroke.
A recent study suggests that stroke patients enrolled in Medicare Advantage plans might get lower-quality post-acute care than those with Original Medicare. That gap seems to widen for patients who also qualify for Medicaid.
The research, published in JAMA Network Open, analyzed national data from more than 44,000 Medicare beneficiaries ages 65 and older who were hospitalized for stroke.
Researchers examined patients discharged to inpatient rehabilitation facilities, skilled nursing facilities or home health agencies. They measured quality using the five-star rating systems 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. The other is Original Medicare, aka traditional Medicare.
Original Medicare is offered directly by the federal government, while private insurers that contract with the government offer Medicare Advantage plans.
Medicare Advantage plans must cover the same services that Original Medicare covers but also can cover other expenses as well. So, Medicare Advantage plans can differ vastly when it comes to coverage and costs — and thus customer satisfaction.
Medicaid is a joint federal and state program that provides health coverage for those with low incomes.
A difference in care
A stroke can dramatically alter a person’s cognitive and physical abilities. That’s why quality rehab care is so critical — for both recovering from a stroke and reducing the risk of another stroke.
Amol Karmarkar, a professor at VCU School of Medicine’s Department of Physical Medicine and Rehabilitation and one of the study’s lead researchers, explains in a summary of the findings:
“Having access to high-quality post-acute care is vital for functional recovery and positive health outcomes for stroke patients, so that they can return to their lives and communities.”
According to the study, among patients who weren’t eligible for Medicaid, those with Medicare Advantage plans were less likely to receive care from highly rated facilities than Original Medicare enrollees:
- Skilled nursing facilities: 53% of Medicare Advantage patients went to highly rated facilities, compared to 58% with Original Medicare
- Home health agencies: 19% of Medicare Advantage patients used highly rated agencies, compared to 22% with Original Medicare
The disparities were more pronounced for “dual-eligible” patients (those on both Medicare and Medicaid), who tend to have higher stroke severity and greater health care needs. Here’s what the study found for skilled nursing facilities:
- Only 42% of dual-eligible Medicare Advantage patients received highly rated care
- Only 44% of dual-eligible Original Medicare patients received highly rated care
Researchers found no statistical difference in care quality for patients discharged to inpatient rehabilitation facilities.
What’s driving the gap?
Researchers point to several potential factors. Medicare Advantage plans often use narrow provider networks to keep costs down, which could limit patient access to more highly rated facilities. Geography may also play a role if higher-rated facilities are farther from where patients live.
Another issue is that many patients, caregivers and providers simply aren’t aware of CMS’ quality rating tools.
“[U]nderstanding these publicly available rating systems is critical because the quality of post-acute care services may ultimately influence a patient’s short-term experience and long-term recovery patterns,” Karmarkar noted.
The bigger picture for Medicare enrollees
Medicare Advantage plans now cover more than half of all Medicare-eligible beneficiaries. Nearly 35.5 million people were enrolled as of Feb. 1. These plans often appeal to seniors with lower premiums, reduced copays and extra benefits.
Unlike Original Medicare, however, they typically require prior authorization for services and restrict enrollees to specific networks of doctors, hospitals and rehab facilities.
For anyone weighing Medicare options, particularly those with health conditions that could increase stroke risk, this research suggests it’s worth investigating what falls within a plan’s network before enrolling.
Taking the time to check the quality ratings of in-network facilities now could make a significant difference in your recovery options later.
Learn more about what to expect from Medicare coverage in “Retirees, Beware: Medicare Will Not Cover These 11 Medical Costs” and “Many People on Medicare Advantage Are Losing Out Because of This Mistake.”