Brain injury patients are getting trapped in the system: How to help

My team sees plenty of familiar faces at our neurosurgery inpatient service. We note them dejectedly during daily rounds. These patients stay in the hospital for months, occasionally years. Some celebrate multiple birthdays in our facility.

They’re no longer actively sick and in need of daily medical interventions — they simply have no place else to go. One main culprit is the structure of Medicaid.

After suffering traumatic brain injuries, many patients are left permanently cognitively impaired, requiring lifetime assistance with daily activities and permanent round-the-clock caregiving. Even for wealthy individuals, it’s a strain on finances and families.

Thus, they can’t be discharged, lingering in medical limbo too healthy to need acute hospitalization yet too disabled to go home. They occupy acute-care beds while patients needing urgent attention pile up in ER hallways or have surgeries canceled because the hospital is full. Acute care nurses are asked to assist these patients with meals, hygiene and supervision, exacerbating nursing shortages.

This is because post-acute care options for patients who cannot discharge home are few. Inpatient rehab facilities can help patients cope with new disabilities but are temporary. Rehab facilities won’t take a patient if there’s no eventual location to discharge to. Thus, patients with few social supports typically need a skilled nursing facility.

How does one finance a lifetime of care?

Medicare and private health insurance typically fund short-term rehab or nursing facility stays, not long-term care, which is funded by private assets, private long-term care insurance or Medicaid. Since most individuals lack the necessary assets or private insurance, Medicaid funds most long-term care. These Medicaid benefits — encompassing post-acute care, nursing homes and home-based community support services — are collectively known as long-term services and supports. Collectively, long-term services and supports take up nearly one-third of Medicaid spending.

States have much leeway in structuring Medicaid. One major variation is offering fee-for-service versus third-party managed care organizations. In fee-for-service, doctors or hospitals submit bills directly to state Medicaid offices for services rendered and get paid their fees. In managed care organization models, private entities receive monthly sums per enrollee, provide care for all enrollees from that pool of funds and keep the balance (or are on the hook for the loss).

States may offer beneficiaries either one or a combination of the two models. Complicating matters, some services might be in one model with others carved out into the other. When long-term services and supports are in a fee-for-service model, this can lead to the disastrous situation traumatic brain injury patients face.

Medicaid fee-for-service typically reimburses at or below cost for skilled nursing facility services. With too many Medicaid patients, a skilled nursing facility can’t pay its staff. A nursing facility can’t be forced to accept patients just because a hospital is overcrowded. A hospital may want a bed freed up but has no recourse. However, when a managed care organization is responsible for all costs associated with a patient’s care, it’s motivated to get the patient out of unnecessary acute care and into post-acute care.

Utilizing managed care puts these incentives to work on the problem. To protect costs, managed care organizations have contracts in both skilled nursing facilities and rehab facilities. Multiple options for medially stabilized patients mean better outcomes. As long as the managed-care market is competitive and patient choice prevails (unfortunately not always the case), they must ensure quality. A reputation for using subpar providers means fewer enrollees.

Ideally, more Americans would already have private long-term care insurance. Medicaid is meant as a safety net for the disabled and destitute, not as the default payer for long-term care. When a patient reaches their private or Medicare coverage limit, they’re left having to use private assets to pay for continued care. They can deplete these assets to “spend down” and qualify for Medicaid, but many protect assets in trusts or property, qualifying while still holding substantial wealth.

State Medicaid agencies should recover these assets more aggressively, reserving Medicaid for the poor. This would encourage broader uptake of private long-term care insurance while leaving Medicaid with more funding for long-term services and supports. This, combined with greater managed care organization long-term service and supports coverage, would increase overall access to post-acute and long-term care services for the old and the young and the temporarily disabled.

More access to post-acute care means more medically stable patients discharged and fewer lingering for months waiting for skilled nursing facility beds. This would free up hospital resources, allowing nurses and doctors to focus on acute patients.

It would improve morale and patient care. I know our clinical team would appreciate it.

Anthony DiGiorgio, DO, MHA, is a neurosurgeon, assistant professor at the University of California, San Francisco School of Medicine, senior affiliated scholar with the Mercatus Center at George Mason University, and the author of a new study, “Traumatic Brain Injury: A Case Study in Failed Incentives to Address the Needs of Medicaid Patients in California.” He is also affiliated faculty at the Institute for Health Policy Studies at UCSF.