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Awaiting insurance coverage: Medicaid enrollment and post-acute care use after traumatic injury
Diane N Haddad1, Justin S Hatchimonji, Ella C Eisinger
1From the Section of Trauma and Acute Care Surgery, Department of Surgery (D.N.H., J.S.H.), University of Chicago, Chicago, Illinois; Perelman School of Medicine (E.C.E., A.T.C., O.I.R., A.U.M., M.K.D., N.D.M., M.J.S., E.J.K.), Division of Trauma, Surgical Critical Care and Emergency Surgery (K.M.C., N.D.M., M.J.S., E.J.K.), University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Surgery (L.M.K.), Stanford University, Stanford, California.
Background:
Lack of insurance after traumatic injury is associated with decreased use of postacute care and poor outcomes. Insurance linkage programs enroll eligible patients in Medicaid at the time of an unplanned admission. We hypothesized that Medicaid enrollment would be associated with increased use of postacute care, but also with prolonged hospital length of stay (LOS) while awaiting insurance authorization.
Methods:
We linked trauma registry and EMR data to identify patients ages 18 years to 64 years admitted from 2017 to 2021 to a Level I trauma center. Patients admitted without insurance and retroactively insured (RI) during hospitalization were compared with patients with established Medicaid (MI) and those remaining uninsured (UI). We measured postacute care use including home health care, rehabilitation, and skilled nursing facilities. We tested the association between insurance status and discharge disposition and LOS (primary outcome) using multivariable negative binomial regression. Direct costs were compared between groups.
Results:
We compared 494 RI patients to 1706 MI and 148 UI patients. Retroactively insured patients had longer hospitalization (median LOS [interquartile range], 4 days [2-9 days]) than other groups (MI, 4 [2-8] and UI 2 [1-3]), p < 0.001). Retroactively insured patients were more likely to be discharged with home health care and to inpatient rehabilitation than UI patients ( p < 0.001). After adjusting for injury and management characteristics, RI was associated with longer LOS compared with MI for patients discharged to inpatient facilities ( p < 0.001). Median costs for RI patients discharged to a facility were $10,284 higher than MI patients, ranging from $8,582 for Injury Severity Score <9 to $51,883 for Injury Severity Score ≥25.
Conclusion:
Enrollment in Medicaid after traumatic injury is associated with postacute care use, but the current enrollment process may delay discharge. Streamlining insurance enrollment and permitting discharge with pending application status could reduce unnecessary hospital days, saving costs and improving improve patient experience.
Level Of Evidence:
Prognostic and Epidemiological; Level IV.
