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

项目摘要/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 这一人群的医疗支出为2590亿美元，其中大部分费用由ADRD患者承担 在养老院(NHS)接受长期护理。由于认知功能减退以及行为和精神疾病 对于ADRD患者所经历的症状，NHS提供的长期护理几乎没有替代品。差一点 三分之二的NH居民患有不同程度的ADRD，其中超过60%的人具有双重资格。全日制居民 ADRD的住院率(45.8%/年)和急诊率(55.3%/年)较高。至.为止 这些事件中有80%与门诊护理敏感情况有关，这些情况是有可能预防的 在NH有适当的初级保健。然而，早期的研究表明，具有双重资格的人 初级保健的质量低于其他受益者。一旦患者成为长期居住的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内科医生应 随着患者痴呆症的进展而处理问题，适当地转介，与其他人协调 提供者，发起和跟踪治疗问题，并与监督患者的家人合作 关心。医疗补助初级保健费用增加提供了一个自然的实验来检查更高的影响 对患有ADRD的符合双重资格的NH居民的护理质量进行医生补偿。两年多的时间 在2013-2014年间，该倡议要求各州的医疗补助计划向提供者报销的费率与 为所有医疗补助患者提供初级保健服务的联邦医疗保险。对于符合双重资格的人，费用上涨需要医疗补助 向提供者报销初级保健服务全部20%的联邦医疗保险共同保险的计划，包括 NHS提供的评估和管理服务。在费用上涨之前和到期后，声明 覆盖了联邦医疗保险B部分共同保险的0至20个百分点。使用所有符合双重条件的国家样本 NH居民在八年内(2011-2018)患有ADRD，该项目将利用自然资源 由医疗补助初级保健费用增加创建的实验，以确定更高的报销对 初级保健服务对这些受益人的护理质量和费用的影响。这将使用两个来源来完成 变动情况：(1)实施及终止加价的时间；及(2) 各州在涨价前后为符合双重资格的人报销全部20%的联邦医疗保险共同保险。 研究设计的准实验性质将允许估计强烈指示因果关系和 我们的全国样本所有符合双重资格的长期居住在NH的ADRD居民将有助于确保结果是 一概而论。该项目将提供非常有价值的证据，表明增加对 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 阿德勒。这一问题具有直接的政策意义，因为31个州没有保持较高的#年偿还率 这些服务在费用上调后于2014年底到期。

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.