New AHA/ASA Policy Statement Urges Stroke Rehab Overhaul

A new policy statement from the American Heart Association/American Stroke Association (AHA/ASA) warns that stroke survivors across the US face steep barriers to rehabilitation, including insurance denials, geographic “care deserts,” and high out-of-pocket costs.

The statement urges policy and performance measure reforms to ensure survivors receive the intensive therapy proven to restore independence.

It was published online on July 31 in Stroke.

Lifeline of Hope

Stroke rehabilitation is the “lifeline of hope” for survivors, their caregivers, and their communities in the days, months, and years after stroke, said the writing group.

Clinical guidelines from the AHA/ASA recommend that discharge planning and rehabilitation decisions be based on a stroke survivor’s functional needs, group chair Nneka Ifejika, MD, MPH, chief scientific officer at Ochsner Health System in New Orleans, noted in a news release.

“However, research shows that nonclinical factors including the size and scope of a hospital network, a patient’s insurance status, and rehabilitation provider availability during the acute stroke hospitalization can limit access to appropriate care, resulting in poorer outcomes and higher long-term costs,” Ifejika said.

The writing group called for enacting measures to ensure full transparency in payer databases on the rehabilitation services patients with stroke receive and their outcomes, as well as the rate of denials for postacute stroke care.

A recent Senate investigation found that a major Medicare Advantage company used artificial intelligence algorithms to deny nearly 1 in 4 requests for postacute stroke care requests in 2022 — double the denial rate just 2 years earlier, the group pointed out.

The writing group also called for:

• Advancing research that reflects real-world stroke recovery challenges by prioritizing patient-centered studies and addressing caregiving needs, mental health, and long-term outcomes such as quality of life, return to work, and community reintegration.
• Developing a national data infrastructure to track rehabilitation service utilization, costs (direct and indirect), and patient outcomes across diverse populations and care settings.
• Evaluating and comparing rehabilitation models for their clinical effectiveness and cost-efficiency to determine what works best for stroke survivors.
• Enhancing care coordination and discharge planning by expanding staff training and addressing the unique needs of patients and their caregivers from varied social and economic backgrounds.
• Studying the impact of systemic factors — such as insurance coverage, geography, health systems, and payment models — on rehabilitation quality and patient recovery to inform improvements in care delivery.

“The quality of one’s recovery from stroke should not depend on their ZIP code, insurance status, or the cultural competency of their healthcare providers when describing the importance of postacute care,” Ifejika said in the release.

“Every stroke survivor should be evaluated to receive high-quality, patient-centered rehabilitation and should have equitable access if postacute care is needed,” Ifejika added.

‘Timely and Important’

Reached for comment, Joseph Broderick, MD, stroke expert and neurologist at the University of Cincinnati, Cincinnati, told Medscape Medical News this is a “very important and timely statement.”

He noted that the problem of postacute care is not at the acute care hospitals, where acute care is standardized, measured, and recognized by certification programs and Get With The Guidelines measurements of key acute care metrics.

“The problem comes when the recommendation for inpatient rehab or skilled nursing facility is made to the insurance carrier and managed governmental programs. There is an incentive to not approve inpatient rehab and particularly long-term acute care — even when the patient meets the criteria,” Broderick said.

Another problem is that insurers that approve where patients are going for postacute care are not open for decision-making and interactions on the weekend. “So a key part of the health system for determining postacute care is not only delaying disposition but doesn’t function 2 days a week,” he noted.

“It would be like pilots in the airline industry not available to fly on the weekends and passengers piling up at the airport and surrounding hotels until Monday, when the pilots came back online and take them to their next destination,” Broderick said.

He noted that cardiac rehab is “universally much clearer and better financially reimbursed than stroke rehab. But it is also much more straightforward than stroke postacute care.”

“Private and government insurers and the postacute facilities need to develop a better system, which is patient-centered rather than money- and profit-driven, standardized with patient and caregiver valued metrics of institutional performance, and a strong push for research to determine how type and intensity of various therapies improve outcome,” Broderick told Medscape Medical News.

“Our stroke patients need us all to do better after they leave the acute care hospital,” he said.

The policy statement was prepared by the volunteer writing group on behalf of the AHA Advocacy Coordinating Committee. Ifejika and Broderick disclosed having no relevant disclosures.