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

项目摘要/摘要 联邦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)住宿。差一点 其中150万是为阿尔茨海默病或相关痴呆症(ADRD)患者及以上患者提供的 100万是为符合双重资格的受益人提供的。住院的ADRD患者患ADRD的可能性是其他患者的四倍 与没有ADRD的患者相比，出院后被送往熟练的护理设施(SNF)。ADRD患者有 更长的住院时间和再住院率，比没有ADRD的患者高出近50%。 在患有ADRD的人中，联邦医疗保险每年为每位受益人在SNF上的花费为6547美元，相比之下，这一数字为448美元 在没有ADRD的受益人中。在SNF接受护理的双重符合条件的人更有可能经历 不良结果，包括再次住院或永久住院，与非 二重奏。SNF中双重符合条件的人经历的许多不良事件被认为是由碎片化引起的 协调不力、有可能通过适当的预防性护理和改进而避免的护理 服务的协调。医疗补助初级保健费用增加提供了一个自然的实验来检查 更高的医生报销对符合双重条件的患有ADRD的SNF患者的护理质量的影响。完毕 在两年的时间里(2013-2014)，该倡议要求各州的医疗补助计划向提供者报销相同的费用 所有医疗补助患者的初级保健服务费率为联邦医疗保险。对于符合双重资格的人，所需的费用增加 医疗补助计划，向提供者报销初级保健服务全部20%的联邦医疗保险共同保险， 包括国家工作队提供的评价和管理服务。在提价之前和之后 到期时，各州涵盖联邦医疗保险B部分共同保险的0至20个百分点。使用全国样本 在八年(2012-2019年)期间，所有符合双重条件的SNF患者患有ADRD，该项目将采取 医疗补助初级保健费用上涨创建的自然实验的优势，以确定 在这些患者的护理质量和费用方面，初级保健服务的报销更高。这将是 使用两个差异来源：(1)执行和终止增加收费的时间 以及(2)之前为符合双重资格的医生报销全部20%的联邦医疗保险共同保险的州的变化 在费用上涨之后。研究设计的准实验性质将使评估成为可能。 说明病因和我们全国所有符合双重条件的患有ADRD的SNF患者的样本将有助于确保 这些结果是可以推广的。该项目将提供非常有价值的证据，表明是否增加了 对初级保健服务的报销提高了双重保健服务的质量和/或降低了双重保健费用- 符合条件的ADRD患者。这一问题具有直接的政策意义，因为31个州没有保持较高的 在2014年底费用上调到期后，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.