Emerging Role of Medicare Advantage in Nursing Home Care

描述(由申请人提供)：25年来，联邦医疗保险政策一直促进受益人参加私人的、承担风险的计划，目前称为联邦医疗保险优势(MA)计划。2006年的《联邦医疗保险现代化法案》(MMA)增加了医疗保险的支付，并补偿了服务于更复杂和虚弱的受益人的计划，刺激了医疗保险人口在过去8年中翻了一番。在养老院居民中，MA注册人数也出现了爆炸性的增长；然而，我们几乎对养老院居民在私人管理护理计划中的护理质量和结果一无所知。这种知识的缺乏影响了我们理解《平价医疗法案》(ACA)中包含的特殊需求扩展和双重合格MA计划的影响。由于联邦医疗保险计划每年向MA计划支付1150亿美元，因此了解它们在照顾虚弱、长期患病的受益人方面新出现的角色对于 告知最优联邦政策。在2000至2010年间，疗养院中MA计划成员的普遍人数从大约16,000人增加到80,000人(约占所有长期居住居民的8%)。这些人中有一半居住在500个护理机构中，每个护理机构都有75个以上 MA计划成员。United Healthcare的“Evercare”计划为居住在疗养院的MA计划受益人提供综合医疗和护理管理服务，与较低的死亡率、较少的可预防住院和每位护士从业人员每年节省约100,000美元的成本有关。值得注意的是，Evercare是在MMA之前以及MA计划随后为急性后和长期护理患者使用疗养院的增长之前启动的。这项研究的长期目标是为改善疗养院弱势居民护理质量和结果的政策努力提供信息。这项申请是我们长期目标的下一步，其目的是研究Medicare Advantage计划对疗养院居民护理的影响，既包括参加这些计划的居民，也包括通过“溢出”效应对非MA居民的影响。这项调查的基本原理是，MA计划在疗养院居民的护理中扮演了迅速增长的角色，他们对管理式护理可能如何影响这些虚弱的慢性病患者知之甚少。我们的中心假设是，疗养院环境中的综合医疗护理，特别是在MA计划居民集中的设施中，对患者结果有积极影响。我们建议使用15年(2000年至2014年)关于MA计划使用护理设施的数据(整合了Medicare注册记录)、向CMS报告的HEDIS数据以及强制性疗养院住院评估最低数据集(MDS)，对这些计划的增长及其对疗养院护理的影响进行全面检查。

DESCRIPTION (provided by applicant): For over 25 years, Medicare policy has promoted beneficiaries' enrollment in private, risk-bearing plans, currently known as Medicare Advantage (MA) plans. The 2006 Medicare Modernization Act (MMA) increased MA payments and compensated plans for serving more medically complex and frail beneficiaries, stimulating a doubling of the MA population over the past 8 years. This explosive growth in MA enrollment has also occurred among nursing home residents; however, we know virtually nothing about the quality and outcomes of care among nursing home residents in private, managed care plans. This lack of knowledge compromises our ability to understand the implications of expansions of special needs and dual eligible MA plans included in the Affordable Care Act (ACA). Because the Medicare program spends $115 billion in annual capitated payments to MA plans, understanding their emerging role in caring for frail, chronically ill beneficiaries is critical to inform optimal federal policy. Between 2000 and 2010 the prevalent population of MA plan members in nursing homes increased from about 16,000 to 80,000 (about 8% of all long stay residents). Half of these individuals reside in only 500 nursing facilities, each with more than 75 MA plan members. United Healthcare's "Evercare" program, which provides integrated medical care and care management services to MA plan beneficiaries residing in nursing homes, was associated with lower mortality, fewer preventable hospitalizations, and cost- savings of approximately $100,000 per year per nurse practitioner. Of note, Evercare was initiated before the MMA and the subsequent growth of MA plans' use of nursing homes for post-acute and long term care patients. The long-term objective of this research is to inform policy efforts to improv the quality and outcomes of care for vulnerable nursing home residents. The objective of this application, which is the next step in our long-range goal, is to examine the impact of Medicare Advantage plans on the care of nursing home residents, both among residents enrolled in these plans as well as on non-MA residents via "spill-over" effects. The rationale that underlies this investigation is that MA plans have assumed a rapidly growing role in the care of nursing home residents with little knowledge about how managed care may impact this frail, chronically-ill population. Our central hypothesis, which is informed by the results of the Evercare evaluation and the paucity of other studies, is that integrated medical cares in the nursing home setting, particularly in facilities where MA plan residents are concentrated, positively affect patient outcomes. We propose to undertake a comprehensive examination of the growth of these plans and their impact on nursing home care using 15 years (2000 through 2014) of data on MA plans' use of nursing facilities that integrates Medicare enrollment records, HEDIS data reported to CMS, and the mandatory nursing home resident assessment minimum data set (MDS).