Discharge disposition from acute care after traumatic brain injury: The effect of insurance type

Objective: To determine if persons with traumatic brain injury (TBI) who are insured by Medicaid or health maintenance organizations (HMOs) are more likely to receive postacute care in skilled nursing facilities (SNFs) than in rehabilitation facilities, compared with persons insured by commercial fee-for-service (FFS) plans. Design: Retrospective cohort study. Setting: County hospital admitting 30% of all Washington State TBI patients. Patients: Patients with moderate to severe TBI discharged to rehabilitation facilities or SNFs between 1992 and 1997 (n = 1271); 56.3% were insured by Medicaid, 26.1% by FFS plans, and 17.6% by HMOs. Interventions: Not applicable. Main Outcome Measures: Disposition on discharge from acute care (rehabilitation facilities vs SNF); adjusted relative risk (RR) and confidence interval (CI) for different insurance types. Results: After accounting for confounding factors, Medicaid patients were 68% more likely (RR = 1.68, 95% CI = 1.34-2.11) and HMO patients were 23% more likely (RR = 1.23, 95% CI =.90-1.68) to go to a SNF than FFS patients. However, the latter difference was not statistically significant. Conclusions: An association exists between insurance type and postacute care site. Efforts should be made to determine the effect this relationship has on the cost and outcomes for TBI patients.