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.

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Research Program Projects (P01)
Project #
2P01AG027296-11
Application #
9490116
Study Section
Special Emphasis Panel (ZAG1)
Project Start
Project End
Budget Start
2019-04-01
Budget End
2020-03-31
Support Year
11
Fiscal Year
2019
Total Cost
Indirect Cost
Name
Brown University
Department
Type
DUNS #
001785542
City
Providence
State
RI
Country
United States
Zip Code
02912
Zhang, Tingting; Zullo, Andrew R; Shireman, Theresa I et al. (2018) Epidemiology of hip fracture in nursing home residents with multiple sclerosis. Disabil Health J 11:591-597
Rahman, Momotazur; Gadbois, Emily A; Tyler, Denise A et al. (2018) Hospital-Skilled Nursing Facility Collaboration: A Mixed-Methods Approach to Understanding the Effect of Linkage Strategies. Health Serv Res 53:4808-4828
McHugh, John P; Zinn, Jacqueline; Shield, Renee R et al. (2018) Strategy and risk sharing in hospital-postacute care integration. Health Care Manage Rev :
Trivedi, Amal N; Leyva, Bryan; Lee, Yoojin et al. (2018) Elimination of Cost Sharing for Screening Mammography in Medicare Advantage Plans. N Engl J Med 378:262-269
Silver, Benjamin C; Rahman, Momotazur; Wright, Brad et al. (2018) Effects of Medicare Medical Reviews on Ambiguous Short-Stay Hospital Admissions. Health Serv Res 53:4747-4766
Li, Qijuan; Rahman, Momotazur; Gozalo, Pedro et al. (2018) Regional Variations: The Use Of Hospitals, Home Health, And Skilled Nursing In Traditional Medicare And Medicare Advantage. Health Aff (Millwood) 37:1274-1281
Tyler, Denise A; McHugh, John P; Shield, Renée R et al. (2018) Challenges and Consequences of Reduced Skilled Nursing Facility Lengths of Stay. Health Serv Res 53:4848-4862
Dore, David D; Zullo, Andrew R; Mor, Vincent et al. (2018) Age, Sex, and Dose Effects of Nonbenzodiazepine Hypnotics on Hip Fracture in Nursing Home Residents. J Am Med Dir Assoc 19:328-332.e2
Berridge, Clara; Tyler, Denise A; Miller, Susan C (2018) Staff Empowerment Practices and CNA Retention: Findings From a Nationally Representative Nursing Home Culture Change Survey. J Appl Gerontol 37:419-434
Thomas, Kali S; Ogarek, Jessica A; Teno, Joan M et al. (2018) Development and Validation of the Nursing Home Minimum Data Set 3.0 Mortality Risk Score (MRS3). J Gerontol A Biol Sci Med Sci :

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