The Impact of Medicare Advantage on ADRD Care and Outcomes

项目摘要 阿尔茨海默病和相关痴呆症（ADRD）患者的死亡率增加了70% 在过去的5年里， 多年的生活。最近的政策努力集中在两个重要和相关的目标，以改善ADRD护理： 支持病人选择留在自己的住所，避免潜在的不必要的， 创伤性住院治疗然而，这些目标的执行情况并不理想， 变化量几乎所有关于ADRD患者的护理和结局的先前研究都来自于 参加传统医疗保险的患者，在管理式护理中对ADRD患者的研究非常少 布局这就造成了一个严重的知识差距，因为在过去12年里， 参加管理式医疗保健（现在称为医疗保险优势）的人数从2004年的530万人增加到1760万人，增加了两倍多。 2016年百万。在管理式医疗下，计划支付资本利率，以承担支付所覆盖的风险。 服务，并对护理质量负责。这些激励措施可能会产生创新的方法， 改善ADRD患者的护理并降低成本。或者，管理式护理计划可以提供 必要服务覆盖不足，避免复杂患者，或促使患者退出 高支出和密集的医疗保健需求。本提案的目的是评估 医疗保险优势在ADRD中以患者为中心的结果的兴起。我们的假设是， 在ADRD患者中，管理式护理的登记将减少长期疗养院的可能性 护理，降低住院率和再入院率，并提高生命末期的护理质量，特别是 在种族/少数民族中，计划侧重于双重资格的患者。然而，这些影响将 在考虑到从医疗保险优势到传统医疗保险的取消登记后，我们的具体 目标是：目标1。在使用家庭医疗服务的ADRD患者中，检查Medicare的效果 长期护理家庭护理和急性住院治疗的优势;目的2。评估医疗保险的效果 ADRD患者急性期后护理结局的优势;目的3。的影响进行评估 医疗保险优势在晚期痴呆症患者生命末期的护理;以及，目标4。评估 这些影响在种族/少数民族人群和不同类型的医疗保险中的异质性 优势计划。该项目将使用所有详细的综合临床和功能评估数据， 美国Medicare认证的家庭健康提供者和疗养院。此外，我们将采用创新的 跨时间差异化方法，利用Medicare Advantage的大幅增长 从2007年到2017年的入学人数，以得出因果推论。我们的贡献是显著的，因为联邦政策 在没有严格的经验证据的情况下， 关于对易受伤害的高成本、高需求人群（如ADRD患者）的健康后果。

PROJECT SUMMARY Persons with Alzheimer’s Disease and Related Dementias (ADRD) suffer from a 70% increase in mortality rates, frequent hospitalizations and medical complications, and catastrophic health care spending in the last 5 years of life. Recent policy efforts have focused on two important and related goals to improve ADRD care: supporting patients’ preferences to remain in their own residence and avoiding potentially unnecessary and traumatic hospitalizations. However, performance on these objectives is suboptimal, with wide geographic variation. Virtually all of the prior research on the care and outcomes of patients with ADRD is derived from patients enrolled in traditional Medicare, with remarkably few studies of persons with ADRD in managed care plans. This raises a critical gap in knowledge because over the past 12 years, the number of beneficiaries enrolled in managed care (now called Medicare Advantage) more than tripled from 5.3 million in 2004 to 17.6 million in 2016. Under managed care, plans are paid a capitated rate to bear the risk of paying for covered services and are held accountable for quality of care. These incentives may yield innovative approaches to improve care and reduce costs for populations with ADRD. Alternatively, managed care plans may provide inadequate coverage of necessary services, avoid complex patients, or promote disenrollment among patients with high spending and intensive health care needs. The objective of this proposal is to evaluate the effects of the rise of Medicare Advantage on patient-centered outcomes in ADRD. Our working hypotheses are that, among persons with ADRD, enrollment in managed care will reduce the likelihood of long-term nursing home care, lower rates of hospitalizations and readmissions, and improve quality of care at the end of life, particularly among racial/ethnic minorities and plans that focus on dual-eligible patients. However, these effects will be attenuated after accounting for disenrollment from Medicare Advantage to traditional Medicare. Our specific aims are: Aim 1. Among patients with ADRD using home health services, examine the effects of Medicare Advantage on long-term nursing home care and acute hospitalizations; Aim 2. Evaluate the effects of Medicare Advantage on the outcomes of post-acute care among patients with ADRD; Aim 3. Evaluate the effects of Medicare Advantage on care at the end of life among patients with advanced dementia; and, Aim 4. Assess the heterogeneity of these effects across racial/ethnic minority populations and different types of Medicare Advantage plans. This project will use detailed comprehensive clinical and functional assessment data from all Medicare-certified home health providers and nursing homes in the US. Further, we will employ an innovative cross-temporal difference-in-differences approach that leverages the dramatic growth in Medicare Advantage enrollment from 2007 to 2017 to draw causal inferences. Our contribution is significant since federal policy continues to promote beneficiaries’ enrollment in risk-bearing private plans without rigorous empirical evidence about the health consequences for vulnerable high-cost, high-need populations, such as those with ADRD.