Investigating Disparities in Home Health Access and Quality for Medicare Beneficiaries with Alzheimer's Disease and Related Dementias Following Recent Payment System Revisions

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PROJECT SUMMARY Of 5.4 million persons with Alzheimer's Disease and Related Dementias (ADRD) in the US, 70% live in the community and are at high risk for unmet care needs. Medicare home health (HH) is a crucial source of care for community-living older adults with ADRD, delivering skilled nursing, therapy, and aide services in the patient's home. Patients can enter HH following an inpatient stay (post-acute HH) or referral by a community physician (Community-Entry Home Health (CEHH)). Nearly half (44%) of Medicare HH episodes are CEHH. Those with ADRD are especially likely to access CEHH. Prior research shows that 30% of CEHH patients have ADRD, compared to just 12% of post-acute HH patients. Recent changes to Medicare HH reimbursement under the Patient-Driven Groupings Model (PDGM) adjust payment by referral source; PDGM is projected to reduce average reimbursement for CEHH by 11% while increasing average reimbursement for post-acute HH by 29% (holding other patient characteristics constant) and does not adjust for patient ADRD status. These changes have prompted concerns that PDGM will negatively impact CEHH patients, especially those with ADRD. The only existing analysis of PDGM's effects on HH utilization fails to examine differences by referral source (community vs post-acute), investigate impacts among vulnerable beneficiary subpopulations, such as those with ADRD, or study changes in patient outcomes. The goal of the proposed research is to assess PDGM's impact on CEHH access, care delivery, and outcomes for community-living older adults with ADRD. We will link Medicare claims, HH assessment, and HH agency data, along with geographic data from the American Community Survey, for a 100% sample of Medicare beneficiaries from 2019-2021. Specific aims are: (1) Characterize PDGM's impact on CEHH access for community-living Medicare beneficiaries with ADRD, (2) Determine PDGM's impact on CEHH care delivery (e.g., number and type of visits) for patients with ADRD, (3) Assess PDGM's association with CEHH outcomes (e.g., hospitalization, Emergency Department visits) for patients with ADRD. In all aims, we will adjust for social and clinical characteristics of the older adult, as well as characteristics of their zip code and state of residence, and the HH agency providing care. PDGM was implemented in 2020, but due to service disruptions related to COVID- 19, we consider 2019 as the “pre” period and 2021 as the “post” period (available evidence shows patient volume and average comorbidity scores stabilized by 2021, reflecting 2019 levels). This research is needed to assess whether a new payment system (PDGM) has contributed to disparities in HH access and quality for those with ADRD. Findings will provide the first evidence regarding PDGM's impacts on CEHH care for those with ADRD and could inform payment system revisions aimed at ensuring accessible, high-quality home-based care for this high-need subpopulation. This work is especially timely given the upward trend in HH utilization and growing numbers of community-living individuals with ADRD.