Higher Reimbursements for Primary Care Services and the Quality of Care for Dually-Eligible Nursing Home Residents with Alzheimer's Disease and Related Dementias.

项目总结/摘要 美国有550万人患有阿尔茨海默病或相关痴呆症（ADRD）。年度健康 这一人群的护理支出为2590亿美元，其中大部分费用归因于ADRD患者 在疗养院接受长期护理。由于认知能力下降以及行为和精神方面的 由于ADRD患者经历的症状，很少有替代品可以替代NHS提供的长期护理。近 三分之二的NH居民有一定程度的ADRD，其中60%以上是双重资格。居民与 ADRD的住院率（45.8%/年）和急诊就诊率（55.3%/年）较高。高达 这些事件中有80%与门诊护理敏感性疾病相关，这些疾病可能是可以预防的 在NH进行适当的初级护理。然而，早期的研究表明，双杀收到 初级保健的质量低于其他受益人。一旦病人成为长期居住的NH居民，NH 医生成为他/她的主要保健提供者。作为初级保健提供者，NH医生预计将 处理问题，因为病人的痴呆症的进展，适当地参考，以协调与其他 提供者，启动和跟进治疗问题，并与家庭成员监督病人的 在乎Medicaid Primary Care Fee Bump提供了一个自然的实验，以检查更高的医疗费用的影响。 医生报销的护理质量的双重资格的NH居民与ADRD。在两年 在2013-2014年期间，该倡议要求各州的医疗补助计划以与 医疗保险为所有医疗补助患者提供初级保健服务。对于双杀，费用增加需要医疗补助 为初级保健服务提供者报销全部20% Medicare共同保险的计划，其中包括 在国家卫生机构提供的评价和管理服务。在费用上涨之前和到期之后， 覆盖0到20个百分点的医疗保险B部分共同保险。使用全国样本的所有双重资格 NH居民与ADRD在八年期间（2011-2018），该项目将利用自然的优势， 由医疗补助初级保健费用颠簸创建的实验，以确定更高的报销对 初级保健服务对这些受益人的保健质量和费用的影响。这将使用两个源来完成 （1）在第（2）款所指的情况下，任何人不得以任何理由将该人的姓名或名称更改为该人的姓名或名称。 在费用上涨之前和之后，州政府为医生报销全部20%的医疗保险共同保险。 研究设计的准实验性质将允许估计强烈指示因果关系， 我们的全国样本的所有双重资格的长期居住NH居民与ADRD将有助于确保结果是 可概括的该项目将提供非常有价值的证据，表明是否增加了对 NHS的初级保健服务提高了双重资格居民的护理质量和/或降低了护理成本， ADRD。这一问题具有直接的政策相关性，因为31个州没有维持较高的偿还率， 这些服务在2014年底费用上涨到期后。

PROJECT SUMMARY/ABSTRACT There are 5.5 million people in the US with Alzheimer’s disease or related dementias (ADRD). Annual health care expenditures for this population are $259 billion with the majority of these costs attributed to ADRD patients receiving long-term care in nursing homes (NHs). Due to the cognitive decline and the behavioral and psychiatric symptoms experienced by ADRD patients, there are few substitutes for long-term care provided by NHs. Nearly two-thirds of NH residents have some degree of ADRD, over 60% of whom are dually-eligible. NH residents with ADRD have high rates of hospitalization (45.8%/year) and emergency department visits (55.3%/year). Up to 80% of these events are associated with ambulatory care sensitive conditions, which are potentially preventable with appropriate primary care in the NH. However, earlier research has indicated that dual-eligibles receive primary care of lower quality than other beneficiaries. Once a patient becomes a long-stay NH resident, the NH physician becomes his/her primary care provider. As the primary care provider, the NH physician is expected to deal with problems as the patient’s dementia progresses, to refer appropriately, to coordinate with other providers, to initiate and follow up on treatment issues, and to work with family members overseeing the patient’s care. 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 NH residents 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 NHs. 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 NH residents with ADRD over an eight-year period (2011-2018), 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 beneficiaries. 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 long-stay NH residents 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 NHs improves the quality and/or lowers the cost of care for dually-eligible residents 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.