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The Association Between Medicare Eligibility and Gains in Access to Rehabilitative Care: A National Regression Discontinuity Assessment of Patients Ages 64 Versus 65 Years

Zogg, Cheryl K. MSPH, MHS; Scott, John W. MD, MPH; Metcalfe, David MSc, MRCS; Seshadri, Anupamaa J. MD; Tsai, Thomas C. MD, MPH; Davis, W. Austin MD; Rose, John A. Jr. MD, MPH; Olufajo, Olubode A. MD, MPH; Zafar, Syed Nabeel MD, MPH; Salim, Ali MD, FACS; Haider, Adil H. MD, MPH, FACS

doi: 10.1097/SLA.0000000000001754
Original Articles

Objectives: The aims of this study were to assess for changes in uninsured rates among trauma patients at age 64 versus 65 years and whether there are associated changes in post-discharge rehabilitation; determine whether changes are driven by rehabilitation provided at home, skilled nursing facilities (SNFs), or acute inpatient facilities; and determine whether changes vary among stratified subgroups of trauma-related “best-practice” factors.

Summary Background Data: Rehabilitation is an important component of high-quality trauma systems with access heavily influenced by insurance status. In the wake of policy changes affecting insurance coverage, it remains unknown the extent to which insurance changes associate with variations in rehabilitation access/use among otherwise similar patients.

Methods: Regression discontinuity models were used to assess for changes in insurance status and rehabilitation at age 64 versus 65 years among adults ages 54 to 75 years (±10 years age-related Medicare eligibility). Data were extracted from the 2007–2012 National Trauma Data Bank.

Results: A total of 305,198 patients were included; 40.1% were discharged to rehabilitation. Medicare eligibility was associated with an abrupt 6.4 (95% confidence interval: 5.8–7.0) percentage-point decline in uninsured and a 9.6 (95% confidence interval: 6.5–12.6) percentage-point increase in rehabilitation at age 64 versus 65 years, enabling an additional 1-in-10 patients to access rehabilitation. Differences were driven by SNF use and were greatest among patients with less-severe clinical presentations. Restriction based on Medicare-payment eligibility to patients with length of stay ≥3days (SNF requirement) and ≥1 “presumptive diagnosis codes” (inpatient facilities’ 60% rule) demonstrated abrupt gains in both SNF and inpatient care.

Conclusions: The results reveal the magnitude of changes in access to rehabilitation associated with changes in insurance coverage at age 65 years. Use of quasiexperimental models enabled meaningful consideration of health-policy change.

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*Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, and the Department of Surgery, Brigham & Women's Hospital, Boston, MA

Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, MA

Department of Surgery, Howard University College of Medicine, Washington, DC.

Reprints: Adil H. Haider, MD, MPH, FACS, Kessler Director Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, 1620 Tremont Street, One Brigham Circle, 4th Floor, Suite 4-020, Boston, MA 02120. E-mail:

This article was previously presented as an oral presentation at the American College of Surgeons Clinical Congress Scientific Forum, 4–8 October 2015, Chicago, IL.

Author contributions: C.K.Z. and J.W.S. made substantial contributions to the conception or design of the work; C.K.Z., J.W.S., and A.H.H. participated in the acquisition and analysis of the data; C.K.Z., J.W.S., D.M., A.J.S., T.C.T., W.A.D., J.A.R., O.O., S.N.Z., A.S., and A.H.H. contributed toward the interpretation of data for the work; C.K.Z., A.J.S., and D.M. drafted the manuscript; and J.W.S., T.C.T., W.A.D., J.A.R., O.O., S.N.Z., A.S., and A.H.H. critically revised the manuscript for intellectual content. All authors provided final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

The authors report no sources of funding or conflicts of interest relevant to the analysis to report. A.H.H. is the PI of a contract (AD-1306–03980) with PCORI entitled “Patient-Centered Approaches to Collect Sexual Orientation/Gender Identity in the ED” and a Harvard Surgery Affinity Research Collaborative (ARC) Program Grant entitled “Mitigating Disparities Through Enhancing Surgeons’ Ability To Provide Culturally Relevant Care.” A.H.H. is also the co-founder and an equity holder in Patient Doctor Technologies Inc., which owns and operates the website

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