Association of Dual Eligibility and Medicare Type With Quality of Postacute Care After Stroke.

Importance: The growth of Medicare Advantage (MA) enrollment has reshaped postacute care utilization, particularly among dual-eligible beneficiaries who experience a disproportionate burden of stroke. Recent evidence shows that MA plans are proactive in managing care and directing enrollees toward narrower networks of postacute facilities for greater efficiency. Objective: To compare the likelihood of discharge to high-quality inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health (HH) care after stroke-related acute hospitalization among dual-eligible Medicare-Medicaid beneficiaries enrolled in MA vs Medicare fee-for-service (FFS) plans. Design, Setting, and Participants: This retrospective cohort study used a 20% random sample of Medicare data and included Medicare beneficiaries aged 65 years or older hospitalized for ischemic stroke between January 1, 2021, and September 3, 2022, with follow-up of postacute care use. The data were analyzed between February 1 and December 28, 2025. Exposure: Dual-eligible Medicare-Medicaid beneficiaries enrolled in FFS vs MA plans. Main Outcomes and Measures: Postacute care quality was assessed using the Centers for Medicare & Medicaid Services' 5-star rating systems for SNFs and HH agencies. For IRFs, quality was defined by the rate of potentially preventable hospital readmissions during the IRF stay. All comparisons were risk adjusted for patient-, hospital-, and region-level factors. Results: In the cohort of 44 078 patients with stroke (mean [SD] age, 79.0 [8.3] years; 57.9% female), 20 497 (46.5%) were non-dual-eligible beneficiaries in FFS, 15 402 (34.9%) were non-dual-eligible beneficiaries in MA, 5256 (11.9%) were FFS dual-eligible beneficiaries, and 6190 (14.0%) were MA dual-eligible beneficiaries. Of the cohort, 17 350 (39.4%) were discharged to IRFs, 16 253 (36.9%) to SNFs, and 10 475 (23.8%) to HH care. There were no significant differences in the quality of IRFs used across groups. Compared with non-dual-eligible FFS beneficiaries, the likelihood of discharge to high-quality SNFs was lower for non-dual-eligible MA beneficiaries (odds ratio [OR], 0.82; 95% CI, 0.74-0.91), dual-eligible FFS beneficiaries (OR, 0.57; 95% CI, 0.50-0.65), and dual-eligible MA beneficiaries (OR, 0.56; 95% CI, 0.50-0.64). Similarly, non-dual-eligible MA beneficiaries were less likely to receive care from high-quality HH agencies (OR, 0.71; 95% CI, 0.62-0.82) compared with non-dual-eligible FFS beneficiaries. Conclusions and Relevance: In this cohort study, dual-eligible and MA-enrolled patients with stroke were less likely to receive postacute care from high-quality SNFs and HH agencies. Equitable access to high-value postacute care is essential to advancing outcomes for high-need, high-risk patients in the era of value-based care.