Health insurance payor type and care deviations in patients with trauma with lower extremity fractures

Lower extremity fractures result in significant morbidity and mortality, with rehabilitation therapy after injury essential to improving outcomes. Understanding how health insurance coverage may act as a benefit or barrier in accessing postacute services is limited. We sought to determine the association of insurance payor type with access to facility-based rehabilitation after sustaining lower extremity fractures and assess for care deviations between qualified provider recommendations and discharge destination.

A retrospective, cross-sectional study was performed at an American College of Surgeons-verified level 1 trauma center and stratified 2570 patients with lower extremity fractures by health insurance payor type (2016-2022). Care deviation was evaluated as discrepancy of final discharge destination from Physical Therapist and Physical Medicine and Rehabilitation physician recommendations.

Traditional and managed Medicare patients were demographically similar and frequently discharged to facility-based rehabilitation (90.5%, 87.7%). Managed Medicare patients were less likely to be discharged to acute rehab (23.6% vs 55.8%) with frequent care deviations from discharge recommendations when compared with traditional Medicare (K=0.40, CI (0.34 to 0.47), K=0.76, CI (0.72 to 0.80)). Medicaid, managed Medicaid, self-pay and privately insured patients were less likely to be discharged to any facility (7.0% to 30.4%), with varying care deviations from discharge recommendations. All payor types were independently predictive of a decreased likelihood of facility-based rehabilitation and higher likelihood of care deviation when compared with traditional Medicare. Managed Medicare was independently predictive of a lower likelihood of discharge to acute rehabilitation (OR 0.46, 95% CI 0.29 to 0.72, p=0.0008).

Patients who sustain lower extremity fractures have highest rates of access to postacute services when covered by traditional Medicare. Frequent care deviation from rehabilitation recommendations in commercially administered insurance programs, especially in managed Medicare, highlights the powerful influence of insurance on adherence with clinician-directed care.

This study meets level III evidence criteria.