Higher Primary Care Reimbursements and the Quality of Care for Dually-Eligible Patients with Alzheimer's Disease and Related Dementias in Skilled Nursing Facilities

项目概要/摘要 医疗保险按服务收费的受益人每年有240万人在熟练护理设施（SNF）停留。近 1.5其中100万人是阿尔茨海默病或相关痴呆症（ADRD）患者， 1000万是双重受益人。住院的ADRD患者中， 与无ADRD的患者相比，出院至专业护理机构（SNF）。ADRD患者有 SNF住院时间更长，再住院率比无ADRD患者高近50%。 医疗保险每年在ADRD患者中为每位受益人花费6，547美元用于SNF停留，而同期为448美元 在没有ADRD的受益者中。在SNF接受护理的双重杀手更有可能经历 不良结局，包括再次住院或永久住院，与非 - 是的SNF中的双杀经历的许多不良事件被认为是由碎片化引起的。 护理协调不良，通过适当的预防护理和改进， 协调服务。Medicaid Primary Care Fee Bump提供了一个自然的实验来检查 更高的医生报销对双重合格SNF ADRD患者护理质量的影响。超过 在为期两年（2013-2014年）的时间里，该倡议要求各州的医疗补助计划向提供者偿还相同的费用。 为所有医疗补助患者提供初级保健服务的医疗保险费率。对于双杀，所需的费用增加 医疗补助计划，以偿还供应商的全部20%的医疗保险共同保险的初级保健服务， 包括SNF提供的评估和管理服务。在费用上涨之前， 到期时，各州覆盖0到20个百分点的医疗保险B部分共同保险。使用全国样本 在8年期间（2012-2019年）所有符合双重条件的SNF ADRD患者中，该项目将 医疗补助初级保健费用增加创造的自然实验的优势，以确定 提高初级保健服务的报销额，以提高这些病人的保健质量和费用。这将是 使用两个变化来源完成：（1）实施和终止费用增加的时间 和（2）各州的变化，报销医生的全部20%的医疗保险共同保险的双杀之前， 在学费上涨之后准实验性质的研究设计将允许估计强烈 表明因果关系和我们的国家样本的所有双重合格的SNF患者与ADRD将有助于确保 结果是可推广的。该项目将提供非常有价值的证据，表明是否增加了 在SNF中对初级保健服务的补偿提高了双重- 符合条件的ADRD患者。这一问题具有直接的政策相关性，因为31个州没有保持较高的 在2014年年底费用增加到期后，这些服务的偿还率。

PROJECT SUMMARY/ABSTRACT Medicare fee-for-service beneficiaries experience 2.4 million skilled nursing facility (SNF) stays annually. Nearly 1.5 million of these stays are for patients with Alzheimer’s disease or related dementias (ADRD) and over 1 million are for dually-eligible beneficiaries. Hospitalized patients with ADRD are four times more likely to be discharged to a skilled nursing facility (SNF) compared to patients without ADRD. Patients with ADRD have longer SNF length of stay and re-hospitalization rates that are nearly 50% higher than for patients without ADRD. Medicare spends $6,547 per beneficiary annually on SNF stays among those with ADRD, compared to $448 among beneficiaries without ADRD. Dual-eligibles who receive care in SNFs are more likely to experience adverse outcomes, including re-hospitalization or becoming permanently institutionalized, compared to non- duals. Many of the adverse events experienced by dual-eligibles in SNFs are thought to arise from fragmented care that is poorly coordinated and are potentially avoidable with proper preventive care and improved coordination of services. The Medicaid Primary Care Fee Bump provides a natural experiment to examine the impact of higher physician reimbursement on the quality of care for dually-eligible SNF patients with ADRD. Over a two-year period (2013-2014), the initiative required states’ Medicaid programs to reimburse providers the same rates as Medicare for primary care services for all Medicaid patients. For dual-eligibles, the fee bump required Medicaid programs to reimburse providers the full 20% Medicare coinsurance for primary care services, which included evaluation and management services provided in SNFs. Prior to the fee bump and following its expiration, states covered 0 to 20 percentage points of Medicare Part B coinsurance. Using a national sample of all dually-eligible SNF patients with ADRD over an eight-year period (2012-2019), this project will take advantage of the natural experiment created by the Medicaid Primary Care Fee Bump to identify the impact of higher reimbursement for primary care services on the quality and cost of care for these patients. This will be done using two sources of variation: (1) the timing of both the implementation and termination of the fee bump and (2) variation in the states reimbursing physicians the full 20% Medicare coinsurance for dual-eligibles before and after the fee bump. The quasi-experimental nature of the research design will allow estimation strongly indicative of causation and our national sample of all dually-eligible SNF patients with ADRD will help ensure that the results are generalizable. The project will provide highly valuable evidence indicating whether increased reimbursement for primary care services in SNFs improves the quality and/or lowers the cost of care for dually- eligible patients with ADRD. This issue has immediate policy relevance as 31 states did not maintain higher reimbursement rates for these services after the fee bump expired at the end of 2014.