UCSF

OBJECTIVES: Timely provision of postacute care (PAC) rehabilitation is critical for achieving functional recovery after traumatic brain injury (TBI). Medicaid coverage is a predictor of prolonged hospital length of stay (LOS) after TBI, a proxy for decreased PAC access. Among Medicaid patients with TBI, it is unknown whether coverage under a managed care organization (MCO) or fee-for-service (FFS) model predicts differences in LOS. STUDY DESIGN: Discharge data for patients with TBI from 318 California hospitals between 2017 and 2019 were obtained. We used multivariable regression models, treating mortality/hospice disposition as competing risks, to evaluate associations between insurance type and LOS, adjusting for sociodemographic factors and illness severity. Sensitivity analysis was conducted in patients with severe TBI identified by receipt of intracranial pressure monitoring or trauma craniotomy/craniectomy. Adjusted HRs (aHRs) were reported. METHODS: The California Department of Health Care Access and Information Patient Discharge Dataset was queried for patients with TBI using International Classification of Diseases, Tenth Revision, Clinical Modification codes. Exclusion criteria were younger than 18 years or older than 65 years, payer other than private insurance (PI) or Medicaid, death or hospice discharge within 5 days of hospitalization, presence of a do-not-resuscitate order, and nonemergency admission. RESULTS: A total of 39,834 patients were analyzed (FFS, 24.2%; MCO, 33.2%; PI, 42.6%). Competing risk regressions showed that Medicaid models were associated with longer LOS compared with PI (FFS: aHR, 0.80; 95% CI, 0.80-0.83; MCO: aHR, 0.92; 95% CI, 0.87-0.96). Compared with MCOs, FFS was associated with longer LOS in the overall cohort (aHR, 0.88; 95% CI, 0.85-0.91) and in the severe TBI subgroup (aHR, 0.90; 95% CI, 0.82-0.99). CONCLUSIONS: Medicaid FFS is associated with increased LOS in hospitalized patients with TBI compared with Medicaid MCOs, suggesting decreased PAC access.