Use of post-acute care and outcomes among Medicare Advantage and fee-for-service beneficiaries

项目摘要 急性期后护理（PAC）是常见的，昂贵的，可能不会导致老年人的最佳健康结果。 然而，目前尚不清楚如何改善PAC的结果和/或降低成本或价值。的40%以上 医疗保险按服务收费（FFS）受益人在住院后接受PAC，主要是熟练护理 医疗设施（SNF）和家庭健康（HH）机构，每年的成本超过600亿美元。不幸的是， 大约四分之一的人在出院后30天内再次入院，近一半的受益人 在SNF中，未在出院后100天内返回社区。医疗保险的快速扩张 优势（MA）提供了一个机会，以评估不同的方法，以PAC的利用。不止一个- 三分之一的医疗保险受益人现在参加了医疗保险优势（MA）计划， 支付费用，并承担受益人护理需求的财务风险。MA计划董事在采访中证实 PAC是通过以下四种机制来减少护理利用和成本的主要重点：限制使用 指导受益人使用较便宜的表格（HH）而不是较昂贵的表格（SNF）; 限制供应商的选择;并限制PAC的停留时间。早期的报告显示，MA计划可能会强烈 影响PAC利用率。在MA中减少PAC利用率是否会提高PAC值尚不清楚。的 有限的现有文献有两个主要的差距：第一，它没有充分考虑到实质性的基础 MA和FFS人群的差异。其次，它关注的是短期结果，而PAC可能 对长期功能状态和独立性有重大影响。我们的总体目标是 患者，提供者和政策制定者关于如何提高PAC对所有医疗保险受益人的价值。 为了实现这一目标，我们提出了创新的分析策略，解决现有文献中的局限性 并允许在类似的MA和FFS受益人中准确评估PAC的使用和结果。我们 目的是：1）比较出院后类似MA和FFS受益人使用SNF和HH的情况，以及 限制PAC使用的不同机制的影响; 2）比较PAC结果（社区日， MA患者出院后100天和1年的长期住院、再住院、死亡率） 和FFS;以及3）评价MA与FFS招募对特定患者亚群的影响 已知有高风险的PAC结果不佳。这些结果将为MA的影响提供新的见解 计划PAC的使用和结果，确定潜在的好处或意外的后果，可以塑造 政策

Project summary Post-acute care (PAC) is common, and costly, and may not lead to optimal health outcomes for older adults. However, it is unknown how to improve outcomes and/or lower costs, or value, of PAC. More than 40% of Medicare fee-for-service (FFS) beneficiaries receive PAC after hospitalization, predominantly in skilled nursing facilities (SNFs) and by home health (HH) agencies, at a cost of more than $60 billion annually. Unfortunately, around 1 in 4 is readmitted to the hospital within 30 days of discharge to PAC, and nearly half of beneficiaries in SNF fail to return to the community within 100 days of hospital discharge. The rapid expansion of Medicare Advantage (MA) provides an opportunity to evaluate a different approach to PAC utilization. More than one- third of all Medicare beneficiaries are now enrolled in Medicare Advantage (MA) plans, which receive capitated payments and take financial risk for the care needs of beneficiaries. MA plan directors confirm in interviews that PAC is a major focus of efforts to reduce care utilization and costs through four mechanisms: limiting use of PAC overall; steering beneficiaries to less expensive forms (HH) instead of more expensive forms (SNF); restricting choice of providers; and limiting PAC length of stay. Early reports suggest MA plans may strongly influence PAC utilization. Whether reductions in PAC utilization in MA improve PAC value is unknown. The limited existing literature has two main gaps: first, it does not adequately account for the substantial underlying differences in the MA and FFS populations. Second, it has focused on short-term outcomes, while PAC likely has a substantial impact on longer-term functional status and independence. Our overall goal is to inform patients, providers, and policymakers about ways to improve the value of PAC for all Medicare beneficiaries. To achieve this goal, we propose innovative analytic strategies that address limitations in the prior literature and allow accurate assessment of the use and outcomes of PAC in similar MA and FFS beneficiaries. Our aims are to: 1) Compare use of SNF and HH in similar MA and FFS beneficiaries after hospital discharge, and the impact of different mechanisms for limiting PAC utilization; 2) Compare PAC outcomes (community days, long-term institutionalization, rehospitalization, mortality) at 100 days and 1 year after hospital discharge in MA and FFS; and 3) Evaluate the effects of MA versus FFS enrollment on specific subpopulations of patients known to be at high risk for poor PAC outcomes. These results will provide novel insights into the effect of MA plans on PAC use and outcomes, identifying potential benefits or unintended consequences that can shape policy.