Relationship of Rehabilitation Insurance Payor to Functional Status at 1 Year Posttraumatic Brain Injury: A Traumatic Brain Injury Model Systems Study

Objective: To determine the contribution of insurance status during inpatient rehabilitation to 1-year functional outcomes in individuals with moderate-to-severe traumatic brain injury. Setting: Post–inpatient rehabilitation discharge. Participants: A total of 8285 individuals with medically documented moderate-to-severe traumatic brain injury who had received acute trauma care and inpatient rehabilitation (5234 non-Hispanic Whites, 1329 non-Hispanic Blacks, 1303 Hispanics, 280 Asians, and 184 Other). Design: Multicenter prospective cohort study. Main Measures: FIM motor and cognitive domains. Results: After adjusting for demographic and injury characteristics, individuals with Medicaid, individuals aged <65 years with Medicare, and those with worker's compensation/auto as their primary insurance had worse FIM cognitive and motor scores at 1 year after injury, relative to those with private insurance/self-pay. An interaction was observed between insurance payor and length of rehabilitation stay, such that the most profound differences in 1-year FIM scores between individuals with private insurance versus individuals aged <65 years with Medicare were among persons with ≥30 days length of stay. Those with Medicaid and those who were aged >65 years with Medicare and no secondary insurance also had lower FIM motor scores than those with private insurance, particularly if their length of stay was ≥30 days. Conclusions: Functional outcomes at 1-year posttraumatic brain injury differ based on insurance type, with relatively poorer functional outcomes among those with public health insurance or worker's compensation/auto insurance. This association was greater among patients with the longest rehabilitation lengths of stay, which likely indicates greater medical complexity. Potential reasons may be less access to postdischarge therapies, but the insurance payor could also be a proxy for socioeconomic position, family support, community resources, and/or neighborhood disadvantages. Individuals in these payor groups may require targeted social work, care coordination, and/or resource facilitation to improve functional outcomes.