A key policy question for the coming decade is how best to structure incentives and regulations to insure that frail older hospitalized patients receie cost effective and coordinated care. Both federal and state policy has transformed long-term care with the emergence of post-acute care provided by nursing homes (NH) and other providers. Post-acute care now represents approximately 20% of all Medicare spending. Our first Program Project grant focused on the effect of states' Medicaid policies on the strategic choices that NHs make and how those choices impact patient outcomes. We find that not only do states' policies influence providers' investments which can positively or adversely affect residents' outcome, we've also found that Medicare policies affected Medicaid providers and states' Medicaid policies affected Medicare patients, often in a dysfunctional manner. Indeed, Medicare policy changes directed at acute hospitals trickle down to impact most NHs further highlighting the interconnectedness of long term and post-acute care policy domains. Thus, Medicaid and Medicare policies are intertwined; when Medicare policies change, even if only directed at hospitals, NHs and other PAC providers are affected. Since the Affordable Care Act (ACA) represents the biggest policy change to Medicare and Medicaid in decades, we believe it is imperative to understand its effects on the acute care and post-acute care interface. The three projects and cores we propose all focus on the growing role of post-acute care (PAC); each has historical aims as well as aims that examine the impact of the Affordable Care Act (ACA). Project #1 asks whether hospitals with strong relationships with NH partners have lower re-hospitalization rates. Project #2 examines the impact of hospitals' approaches to staffing the attending physician role on frail, hospitalized NH residents experience. Finally, Project #3 examines, for the first time, the use of PAC by Medicare managed care and how patients respond to changing co-pay structures for PAC.

Public Health Relevance

Over the last 4 decades long term care in America has been transformed and is now increasingly serving as post-acute care for Medicare beneficiaries recovering from illness. Since the Affordable Care Act (ACA) is the biggest Medicare policy change in decades, we seek to study the evolution of post-acute care and its response to the many ACA provisions affecting the scope of hospitals' responsibility post-discharge.

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Research Program Projects (P01)
Project #
5P01AG027296-09
Application #
9232047
Study Section
Special Emphasis Panel (ZAG1-ZIJ-3 (01))
Program Officer
Bhattacharyya, Partha
Project Start
2005-12-01
Project End
2019-01-31
Budget Start
2017-02-01
Budget End
2018-01-31
Support Year
9
Fiscal Year
2017
Total Cost
$1,201,907
Indirect Cost
$430,700
Name
Brown University
Department
Public Health & Prev Medicine
Type
Schools of Public Health
DUNS #
001785542
City
Providence
State
RI
Country
United States
Zip Code
02912
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Keohane, Laura M; Trivedi, Amal N; Mor, Vincent (2018) The Role of Medicare's Inpatient Cost-Sharing in Medicaid Entry. Health Serv Res 53:711-729
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Kumar, Amit; Rahman, Momotazur; Trivedi, Amal N et al. (2018) Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data. PLoS Med 15:e1002592
Berry, Sarah D; Zullo, Andrew R; Lee, Yoojin et al. (2018) Fracture Risk Assessment in Long-term Care (FRAiL): Development and Validation of a Prediction Model. J Gerontol A Biol Sci Med Sci 73:763-769
Thomas, Kali S; Silver, Benjamin; Gozalo, Pedro L et al. (2018) Constructing a Measure of Private-pay Nursing Home Days. Med Care 56:e26-e31
Rivera-Hernandez, Maricruz; Kumar, Amit; Epstein-Lubow, Gary et al. (2018) Disparities in Nursing Home Use and Quality Among African American, Hispanic, and White Medicare Residents With Alzheimer's Disease and Related Dementias. J Aging Health :898264318767778
Kosar, Cyrus M; Thomas, Kali S; Gozalo, Pedro L et al. (2018) Effect of Obesity on Postacute Outcomes of Skilled Nursing Facility Residents with Hip Fracture. J Am Geriatr Soc 66:1108-1114
McCreedy, Ellen M; Weinstein, Barbara E; Chodosh, Joshua et al. (2018) Hearing Loss: Why Does It Matter for Nursing Homes? J Am Med Dir Assoc 19:323-327

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