Improving the Quality of Care Provided Through Bundled Payments for Patients with Alzheimer's Disease or Other Forms of Dementia or Frailty

住院后的急性后护理(PAC)帮助功能状况不佳的患者-包括 越来越多患有阿尔茨海默氏症和其他形式的痴呆症和/或虚弱的脆弱老年人-使 通过出院后提供的康复服务成功过渡到家中。政治行动委员会是最快的- 医疗保险支出中不断增长的部分促使医疗保险越来越多地过渡到新的支付模式 这就产生了强大的动机来减少政治行动委员会的护理。 医疗改善捆绑支付(BPCI)是一项大规模的自愿医疗保险支付改革 该倡议始于2013年。在BPCI3的“模式3”中，PAC提供者照顾一名或一名出院病人 在48种有针对性的疾病中，有更多的人承担30、60或90岁以上的急性后护理的全部费用- 出院和PAC入院后的一天，包括任何重新入院、紧急护理 或门诊就诊。发作可以通过将护理从医院转移到熟练的护理机构而开始 家庭健康机构、康复医院或长期护理医院。截至2017年7月，1143集 发起组织参加了BPCI，其中76%是SNF。如果医疗保险的支付金额较低 与历史医疗费用相比，参保人能够保留部分节省；如果联邦医疗保险支付超过 目标参与者将承担部分超额费用。 捆绑支付为PAC提供商提供强大的激励，以更好地协调服务和 重新设计护理，这可能对脆弱的老年人非常有帮助，另一方面，这样的计划可以 也会诱使提供者在护理上吝啬或避免这些患者。确定支付的真正影响 像BPCI这样的改革需要评估以下两方面：(1)PAC提供者如何重新设计医疗服务以实现更好的结果 和更低的成本，以及(2)它们是否节省了护理或减少了对高需求患者的获得。 我们计划：1)使用管理来确定BPCI是否与恶化的访问有关 痴呆症和/或虚弱患者的护理和临床结果；2)利用全国SNF调查 确定BPCI参与者重新设计痴呆症和/或虚弱患者护理的策略； 以及3)组合这两个数据源以确定是否有任何用于护理重新设计的特定策略相关联 改善痴呆症和/或虚弱患者的预后。 这些综合证据将有意义地促进我们对如何设计政策的理解 激励向易受伤害的老年人提供高质量、经济高效的PAC并避免意外 负面后果。

Post-acute care (PAC) after a hospitalization helps patients with poor functional status – including the growing number of vulnerable older adults with Alzheimer’s and other forms of dementia and/or frailty – make a successful transition to home through rehabilitation services provided after discharge. PAC has been fastest- growing segment of Medicare spending prompting Medicare to increasingly transition to new payment models that create strong incentives to reduce PAC care. Bundled Payments for Care Improvement (BPCI) is a large, voluntary Medicare payment reform initiative that started in 2013. In BPCI’s “Model 3,” PAC providers caring for patients discharged with one or more of 48 targeted conditions assume responsibility for the entire cost of post-acute care over a 30, 60 or 90- day period subsequent to hospital discharge and PAC admission, including any readmissions, emergency care or outpatient visits. Episodes can be initiated by transfer of care from a hospital to a skilled nursing facility (SNF), home health agency, rehabilitation hospital, or long-term care hospital. As of July 2017, 1143 episode initiating organizations were participating in BPCI, of which 76% were SNFs. If Medicare payments are lower than historical costs of care, enrollees are able to keep a portion of the savings; if Medicare payments exceed the target enrollee will be responsible for part of the overage. Bundled payments provide strong incentives for PAC providers to better-coordinate services and redesign care, which could be very helpful for vulnerable older adults On the other hand, such programs could also induce providers to skimp on care or avoid these patients. Determining the true impact of payment reforms like BPCI requires evaluating both (1) how PAC providers redesign care to achieve better outcomes and lower costs, and (2) whether they skimp on care or reduce access for high need patients. We plan to: 1) use administrative to determine whether BPCI was associated with worsening access to care and clinical outcomes for patients with dementia and/or frailty; 2) use a national survey of SNFs to determine the strategies used by BPCI participants to redesign care for patients with dementia and/or frailty; and 3) combine these two data sources to determine if any specific strategies for care redesign are associated with improvements in outcomes for patients with dementia and/or frailty. This combined evidence will meaningfully advance our understanding of how to design policies to incentivize the delivery of high-quality, cost-effective PAC to vulnerable older adults and avoid unintended negative consequences.