The Impact of Medicare Advantage on ADRD Care and Outcomes

项目总结 阿尔茨海默病和相关痴呆症(ADRD)患者死亡率增加70% 过去5年的比率、频繁住院和医疗并发症以及灾难性的医疗保健支出 生命中的岁月。最近的政策努力侧重于改善ADRD护理的两个重要且相关的目标： 支持患者留在自己的住所的偏好，避免可能不必要的和 创伤住院治疗。然而，在这些目标上的绩效并不是最优的，地域范围很广 变种。几乎所有先前关于ADRD患者的护理和预后的研究都源于 参加传统医疗保险的患者，在管理性医疗中对ADRD患者的研究非常少 计划。这造成了知识上的严重差距，因为在过去的12年里，受益者的数量 参加管理型医疗(现在称为Medicare Advantage)的人数从2004年的530万人增加到1760万人，增长了两倍多 2016年为100万人。在管理型医疗保健下，计划按首肯的费率支付，以承担支付承保费用的风险 并对护理质量负责。这些激励措施可能会产生创新的方法来 改善对患有ADRD的人群的护理并降低成本。或者，管理型护理计划可以提供 对必要服务的覆盖不足，避免复杂的患者，或促进患者退保 有高支出和密集的医疗保健需求。这项建议的目的是评估以下各项的效果 医疗保险优势的兴起对ADRD以患者为中心的结果。我们的假设是， 在ADRD患者中，参加管理型护理将降低长期入住养老院的可能性 护理，降低住院率和再住院率，提高生命末期的护理质量，特别是 在种族/民族少数群体中，以及以双重资格患者为重点的计划。然而，这些影响将是 在计入从Medicare Advantage到传统Medicare的退保后衰减。我们的特定 目标是：目标1.在使用家庭卫生服务的ADRD患者中，检查医疗保险的效果 长期养老院护理和急性住院的优势；目的2.评估医疗保险的效果 对ADRD患者急性后护理结果的优势；目的3.评估 在晚期痴呆症患者生命末期护理方面的医疗保险优势；以及，目标4.评估 这些影响在种族/少数民族人口和不同类型的医疗保险中的异质性 优势计划。该项目将使用详细的、全面的临床和功能评估数据 美国医疗保险认证的家庭健康提供者和疗养院。此外，我们将采用一种创新的 利用联邦医疗保险优势显著增长的跨时期差异方法 2007年至2017年招生，以得出因果推论。我们的贡献是巨大的，因为联邦政策 继续推动受益人在没有严格经验证据的情况下参加有风险的私人计划 关于弱势、高成本、高需求人群的健康后果，例如患有ADRD的人群。

PROJECT SUMMARY Persons with Alzheimer’s Disease and Related Dementias (ADRD) suffer from a 70% increase in mortality rates, frequent hospitalizations and medical complications, and catastrophic health care spending in the last 5 years of life. Recent policy efforts have focused on two important and related goals to improve ADRD care: supporting patients’ preferences to remain in their own residence and avoiding potentially unnecessary and traumatic hospitalizations. However, performance on these objectives is suboptimal, with wide geographic variation. Virtually all of the prior research on the care and outcomes of patients with ADRD is derived from patients enrolled in traditional Medicare, with remarkably few studies of persons with ADRD in managed care plans. This raises a critical gap in knowledge because over the past 12 years, the number of beneficiaries enrolled in managed care (now called Medicare Advantage) more than tripled from 5.3 million in 2004 to 17.6 million in 2016. Under managed care, plans are paid a capitated rate to bear the risk of paying for covered services and are held accountable for quality of care. These incentives may yield innovative approaches to improve care and reduce costs for populations with ADRD. Alternatively, managed care plans may provide inadequate coverage of necessary services, avoid complex patients, or promote disenrollment among patients with high spending and intensive health care needs. The objective of this proposal is to evaluate the effects of the rise of Medicare Advantage on patient-centered outcomes in ADRD. Our working hypotheses are that, among persons with ADRD, enrollment in managed care will reduce the likelihood of long-term nursing home care, lower rates of hospitalizations and readmissions, and improve quality of care at the end of life, particularly among racial/ethnic minorities and plans that focus on dual-eligible patients. However, these effects will be attenuated after accounting for disenrollment from Medicare Advantage to traditional Medicare. Our specific aims are: Aim 1. Among patients with ADRD using home health services, examine the effects of Medicare Advantage on long-term nursing home care and acute hospitalizations; Aim 2. Evaluate the effects of Medicare Advantage on the outcomes of post-acute care among patients with ADRD; Aim 3. Evaluate the effects of Medicare Advantage on care at the end of life among patients with advanced dementia; and, Aim 4. Assess the heterogeneity of these effects across racial/ethnic minority populations and different types of Medicare Advantage plans. This project will use detailed comprehensive clinical and functional assessment data from all Medicare-certified home health providers and nursing homes in the US. Further, we will employ an innovative cross-temporal difference-in-differences approach that leverages the dramatic growth in Medicare Advantage enrollment from 2007 to 2017 to draw causal inferences. Our contribution is significant since federal policy continues to promote beneficiaries’ enrollment in risk-bearing private plans without rigorous empirical evidence about the health consequences for vulnerable high-cost, high-need populations, such as those with ADRD.