From the publishers of the New England Journal of Medicine

 

Stroke patients in Medicare HMOs are less likely to receive rehabilitation and more likely to be sent to nursing homes than patients in traditional fee-for-service plans, according to a study in the July 9 Journal of the American Medical Association.

The researchers found that of about 400 stroke patients enrolled in HMOs in 12 states, 42 percent went into nursing homes, and only 16 percent were sent to rehab hospitals or units. Among a similar group of fee-for-service patients, 28 percent were discharged to nursing homes and 23 percent to rehab. Other patients were sent home. Death rates were comparable during the average 30-month follow-up.

Given this discrepancy, how can you be certain of the best post-stroke care, regardless of payment method?

The researchers, from Virginia Commonwealth University, say their study doesn't show whether rehab is used too much by fee-for-service patients or too little by HMO patients.

Traditional Medicare patients choose their doctors and hospitals, which are paid by Medicare for each service provided. In Medicare HMOs, the plan receives a lump sum per patient up front, which has led to concerns that some services for sick patients might be curtailed. Because prior research shows that stroke patients who receive rehabilitation have a greater chance of returning home, family members should be assertive about making sure the patient is evaluated for rehab, the researchers say.

Medicare covers a stay in a rehab hospital completely for 20 days and partially for 80 more, regardless of a senior's pay plan. To qualify, a patient physically must be able to participate in three hours of daily therapy and be mentally willing and able to cooperate. A neurologist, a geriatrician, or a physician at a rehab hospital can assess whether a patient is a suitable candidate for rehab, says James Webster, MD, of Northwestern University's Buehler Center on Aging in Chicago, who also wrote an editorial accompanying the study. He said family members of HMO patients should appeal to the primary care doctor to make sure that any patient capable of rehab is offered the opportunity.

"Too many physicians still look at stroke as an unfortunate act of God for which there is no treatment," Dr. Webster says. "But we have lots of good data showing that rehab helps."

HMOs Return