Higher Primary Care Reimbursements and the Quality of Care for Dually-Eligible Patients with Alzheimer's Disease and Related Dementias in Skilled Nursing Facilities

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PROJECT SUMMARY/ABSTRACT Medicare fee-for-service beneficiaries experience 2.4 million skilled nursing facility (SNF) stays annually. Nearly 1.5 million of these stays are for patients with Alzheimer’s disease or related dementias (ADRD) and over 1 million are for dually-eligible beneficiaries. Hospitalized patients with ADRD are four times more likely to be discharged to a skilled nursing facility (SNF) compared to patients without ADRD. Patients with ADRD have longer SNF length of stay and re-hospitalization rates that are nearly 50% higher than for patients without ADRD. Medicare spends $6,547 per beneficiary annually on SNF stays among those with ADRD, compared to $448 among beneficiaries without ADRD. Dual-eligibles who receive care in SNFs are more likely to experience adverse outcomes, including re-hospitalization or becoming permanently institutionalized, compared to non- duals. Many of the adverse events experienced by dual-eligibles in SNFs are thought to arise from fragmented care that is poorly coordinated and are potentially avoidable with proper preventive care and improved coordination of services. 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 SNF patients 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 SNFs. 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 SNF patients with ADRD over an eight-year period (2012-2019), 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 patients. 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 SNF patients 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 SNFs improves the quality and/or lowers the cost of care for dually- eligible patients 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.