Medicare Advantage and End of Life Care for Patients with Advanced Dementia

晚期痴呆症患者的医疗保险优势和临终关怀

• 批准号: 10056604
• 负责人: Kanika Arora
• 金额: $ 7.44万
• 依托单位: UNIVERSITY OF IOWA
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-08-15 至 2022-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10056604
• 关键词: Accounting; Address; Affordable Care Act; Aging; Alzheimer' s disease related dementia; American; Area; Back; Caring; Categories; Cessation of life; Chronic Care; Complex; Continuity of Patient Care; Contracts; Cost Control; Cost Sharing; Data; Dementia; Development; Diagnosis; Enrollment; Evaluation; Expenditure; Face; Fee-for-Service Plans; Future; Growth; Health; Health Care Reform; Health Personnel; Health Services; Health Services Accessibility; Health and Retirement Study; Heterogeneity; Home environment; Hospitalization; Incentives; Individual; Insurance; Insurance Coverage; Investigation; Length of Stay; Link; Literature; Managed Care Programs; Measures; Medical; Medicare; Methodology; Modeling; Outcome; Pain; Pain management; Palliative Care; Patient Care; Patient-Focused Outcomes; Patients; Pattern; Patterns of Care; Persons; Policies; Population; Positioning Attribute; Procedures; Provider; Quality of Care; Reporting; Role; Sampling; Selection Bias; Service delivery model; Services; Site; Specialist; Surveys; Terminal Disease; Terminally Ill; Time; Training; advanced dementia; advanced disease; aggressive therapy; aging population; base; beneficiary; care coordination; care delivery; care outcomes; care providers; end of life; end of life care; financial incentive; health plan; health service use; hospice environment; innovation; mortality; payment; population based; preference; programs; symptom management; trend

Even though a growing number of Americans are dying with dementia, several receive suboptimal care near the end of life. Reported problems include under-diagnosis and poor treatment of pain, painful and unnecessary investigations and inappropriate use of aggressive treatments. Some studies have reported that capitated Medicare-Advantage (MA) plans, that are paid on a per-person (rather than a per-service) basis, may be better positioned than traditional fee-for-service Medicare to promote the use of recommended services at the end of life while discouraging unnecessary hospitalizations and invasive procedures. In addition, the hospice “carve-out” also creates a strong financial incentive for MA plans to promote hospice enrollment among their terminally ill patients. On the other hand, capitated payments incentivize MA plans to selectively contract with health providers and restrict services and choice of providers in order to control costs. MA beneficiaries face higher cost-sharing if they receive care from providers outside of their network. Narrow networks can also influence quality of care directly if higher-quality providers are unwilling to accept low payment rates. Therefore, the relationship between MA enrollment on service use and quality of care is potentially a mixture of different effects that vary across outcomes and patients, necessitating robust empirical evidence on both the direction and magnitude of these effects. Much of existing literature in this area focuses on the use of a few health services, does not account for potential selection bias in MA enrollment, precedes enrollment changes accompanying the 2010 health reform, and does not specifically focus on dementia patients. Our study employs multiple waves of unique population- based mortality follow-back data associated with the Health and Retirement Study (HRS) (2000- 2014) and the National Health and Aging Trends Study (NHATS) (2012-2017) to examine the relationship between MA enrollment and three categories of end of life care outcomes: patterns of care (including site of death), out-of-pocket expenditures and perceived quality of end of life care, among dementia decedents. It also harnesses the core HRS and NHATS files to account for longitudinal patterns of insurance coverage among dementia decedents. We also propose several sensitivity and heterogeneity analyses to enhance the robustness of our findings.

尽管越来越多的美国人死于痴呆症，但仍有一些人接受了治疗 临终时的护理欠佳。报告的问题包括诊断不足和不良 治疗疼痛、痛苦和不必要的检查以及不恰当地使用积极的方法 治疗。一些研究报告称，按人头计算的 Medicare-Advantage (MA) 计划， 按人（而不是按服务）付费，可能比 传统的按服务收费的医疗保险，以促进年底推荐服务的使用 生活，同时阻止不必要的住院治疗和侵入性手术。此外， 临终关怀“剥离”也为 MA 计划促进临终关怀创造了强大的财务激励 纳入绝症患者。另一方面，按人头付费激励 MA 计划有选择地与医疗服务提供者签订合同，并限制服务和选择 供应商为了控制成本。如果 MA 受益人接受护理，他们将面临更高的费用分摊 来自其网络之外的提供商。狭窄的网络也会影响护理质量 如果更高质量的提供商不愿意接受低付款率，则可以直接进行。因此， MA 注册与服务使用和护理质量之间的关系可能是以下因素的混合体： 不同的效果因结果和患者而异，需要强有力的经验证据 这些影响的方向和程度。该领域的许多现有文献 重点关注少数医疗服务的使用，没有考虑 MA 中潜在的选择偏差 招生，先于 2010 年医疗改革的招生变化，并且不 特别关注痴呆症患者。我们的研究采用了多波独特人群—— 基于与健康和退休研究 (HRS) 相关的死亡率跟踪数据（2000- 2014）和国家健康与老龄化趋势研究（NHATS）（2012-2017）来检查 硕士入学与三类临终关怀结果之间的关系：模式 护理（包括死亡地点）、自付费用和临终感知质量 照顾痴呆症死者。它还利用核心 HRS 和 NHATS 文件来计算 痴呆症死者保险范围的纵向模式。我们还建议 一些敏感性和异质性分析以增强我们研究结果的稳健性。