Effect of Medicare Reimbursement for Care Planning on End of Life Care among Patients with Alzheimer's Disease and Related Dementias: A Quasi-Experimental Study

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PROJECT SUMMARY Alzheimer's disease and Alzheimer's Disease-related dementias (AD/ADRD) are a leading cause of death in the U.S. More than 40% of all Medicare patients who die in a given year have AD/ADRD, and the number of deaths from AD/ADRD are fast growing. Dying individuals with AD/ADRD use more aggressive care at end of life, including burdensome transitions to the hospital and invasive procedures of questionable benefit, compared to those with no cognitive impairment. Advance care planning (ACP), the process of discussing and recording patient preferences for goals of care in the event of patient losing capacity, has been shown to decrease aggressive treatment and increase use of hospice and palliative care, in particular among AD/ADRD patients. Barriers to ACP exist, and no research has examined the causal effect of ACP on end-of-life (EOL) care among AD/ADRD patients using national data. This proposal addresses these gaps by examining two recent changes in Medicare reimbursement policy: the introduction of ACP billing codes on January 1, 2016, and the introduction of comprehensive care planning (CCP) billing codes on January 1, 2017. The CCP targets cognitively impaired patients and consists of several mandated components, including development, revision or review of an Advance Care Plan. No direct evidence exists on the effect of these two reimbursement changes on EOL care; in general or among AD/ADRD patients. This proposal will utilize Medicare claims data merged with several supplementary data sources to examine multiple physician and patient factors associated with ACP and CCP billing, and will innovatively apply two quasi-experimental study designs to separately examine the causal effect of ACP and CCP billing on EOL care spending and multiple measures of EOL care utilization commonly used as indicators for quality of EOL care, among AD/ADRD patients nationwide. Advanced statistical learning techniques will be employed to further correct bias and improve precision of causal estimates. The Specific Aims are: (1) To identify the physician and patient characteristics associated with ACP and CCP billing for AD/ADRD patients; (2) To determine the effect of ACP billing on EOL care utilization and spending among AD/ADRD patients using a Regression Discontinuity Design (RDD); (3) To determine the effect of CCP billing on EOL care utilization and spending among AD/ADRD patients using an Instrumental Variables (IV) approach. IMPACT: This project will provide rigorous and critical evidence to directly inform effective policies targeted at improving EOL care for AD/ADRD patients. Further, this K01 application will establish the applicant as one the few health economists with expertise in AD/ADRD, geriatrics and palliative care. It will prepare her to become an R01-funded independent investigator in policy evaluations that lead to improved quality of care and quality of life for the aging population, in particular AD/ADRD patients.