Improving the Quality of Care Provided Through Bundled Payments for Patients with Alzheimer's Disease or Other Forms of Dementia or Frailty

通过捆绑式支付为阿尔茨海默病患者提供的护理质量 疾病或其他形式的痴呆或虚弱：摘要 住院后的急性期后护理（PAC）可帮助功能状态较差的患者-包括 越来越多的易受伤害的老年人患有阿尔茨海默氏症和其他形式的痴呆症和/或虚弱-使 通过出院后提供的康复服务，成功过渡到家庭。PAC是最快的- 不断增长的医疗保险支出促使医疗保险越来越多地过渡到新的支付模式 这就产生了强烈的动机来减少PAC护理。 Bundled Payments for Care Improvement（BPCI）是一项大型的自愿医疗保险支付改革 该倡议始于2013年。在BPCI的“模型3”中，PAC提供者照顾出院的患者， 超过48个目标条件承担了超过30，60或90的急性后护理的全部费用， 出院和PAC入院后的一天内，包括任何再入院、急诊护理 或门诊病人。由医院转移到专业护理机构进行护理，即可启动Epperiment (SNF)、家庭保健机构、康复医院或长期护理医院。截至2017年7月，1143集 发起组织参与了BPCI，其中76%是SNF。如果医疗保险支付较低， 比历史护理成本，登记者能够保留一部分储蓄;如果医疗保险支付超过 目标登记者将负责部分超额。 捆绑支付为PAC提供商提供了强有力的激励，以更好地协调服务， 重新设计护理，这可能对脆弱的老年人非常有帮助。另一方面， 这也会导致医疗服务提供者在护理上吝啬或避开这些病人。确定付款的真实影响 像BPCI这样的改革需要评估（1）PAC提供者如何重新设计护理以实现更好的结果 降低成本，以及（2）他们是否在护理上吝啬或减少对高需求患者的访问。 我们计划：1）使用管理来确定BPCI是否与恶化的访问相关， 痴呆和/或虚弱患者的护理和临床结局; 2）使用SNF的全国调查， 确定BPCI参与者使用的策略，以重新设计痴呆和/或虚弱患者的护理; 和3）联合收割机这两个数据源，以确定是否有任何具体的护理重新设计的战略相关联 改善痴呆和/或虚弱患者的预后。 这些综合证据将有意义地推进我们对如何设计政策的理解， 激励向弱势老年人提供高质量，具有成本效益的PAC，并避免意外 负面后果。

Improving the Quality of Care Provided Through Bundled Payments for Patients with Alzheimer's Disease or Other Forms of Dementia or Frailty: Abstract Post-acute care (PAC) after a hospitalization helps patients with poor functional status – including the growing number of vulnerable older adults with Alzheimer's and other forms of dementia and/or frailty – make a successful transition to home through rehabilitation services provided after discharge. PAC has been fastest- growing segment of Medicare spending prompting Medicare to increasingly transition to new payment models that create strong incentives to reduce PAC care. Bundled Payments for Care Improvement (BPCI) is a large, voluntary Medicare payment reform initiative that started in 2013. In BPCI's “Model 3,” PAC providers caring for patients discharged with one or more of 48 targeted conditions assume responsibility for the entire cost of post-acute care over a 30, 60 or 90- day period subsequent to hospital discharge and PAC admission, including any readmissions, emergency care or outpatient visits. Episodes can be initiated by transfer of care from a hospital to a skilled nursing facility (SNF), home health agency, rehabilitation hospital, or long-term care hospital. As of July 2017, 1143 episode initiating organizations were participating in BPCI, of which 76% were SNFs. If Medicare payments are lower than historical costs of care, enrollees are able to keep a portion of the savings; if Medicare payments exceed the target enrollee will be responsible for part of the overage. Bundled payments provide strong incentives for PAC providers to better-coordinate services and redesign care, which could be very helpful for vulnerable older adults On the other hand, such programs could also induce providers to skimp on care or avoid these patients. Determining the true impact of payment reforms like BPCI requires evaluating both (1) how PAC providers redesign care to achieve better outcomes and lower costs, and (2) whether they skimp on care or reduce access for high need patients. We plan to: 1) use administrative to determine whether BPCI was associated with worsening access to care and clinical outcomes for patients with dementia and/or frailty; 2) use a national survey of SNFs to determine the strategies used by BPCI participants to redesign care for patients with dementia and/or frailty; and 3) combine these two data sources to determine if any specific strategies for care redesign are associated with improvements in outcomes for patients with dementia and/or frailty. This combined evidence will meaningfully advance our understanding of how to design policies to incentivize the delivery of high-quality, cost-effective PAC to vulnerable older adults and avoid unintended negative consequences.