An estimated 5.3 million Americans have Alzheimer?s disease and related dementias (ADRD) in 2015, and that number is expected to increase to around 15 million by 2050. Nursing homes (NHs) are a critical site of care of persons with ADRD?both for patients needing post-acute care (PAC) so they can return home and for patients who can no longer live at home and need long-term care. However, NHs face financial dis-incentives to admit persons with ADRD?who are costly to care for, generate less revenue than other patients, require longer lengths of stay, and are less likely to be successfully discharged from the NH. These financial disincentives are exacerbated by current trends in segmentation of the NH market into two distinct tiers?high- resourced NHs specializing in higher-margin, higher-quality PAC and low-resourced and low-quality NHs serving long-stay Medicaid residents reimbursed at or below cost. Not surprisingly, persons with ADRD suffer in this two-tier market. In recent years, NH market segmentation has increased with the rise of alternative payment models including growth in Medicare Advantage (MA), the emergence of accountable care organizations (ACOs), and the introduction of bundled payments, with providers developing preferred provider networks to direct their patients toward the most efficient NHs. How care for persons with ADRD will change under alternative payment models is unclear. On the one hand, the narrowing of PAC networks has the potential to provide NHs with further disincentives to admit patients with ADRD. On the other hand, alternative payment models may cause insurers and hospital systems to be more active in managing persons with ADRD, with more emphasis on providing high-quality care that will maximize their potential to return to their pre-morbid functioning rather than becoming a long-stay nursing home resident. The purpose of this study is to determine whether ADRD represents a barrier to admission to higher quality NHs; i.e. dementia as a disparity; and to test whether this disparity is ameliorated under emerging new payment models ranging from MA to ACOs to hospitals operating under the bundles. Building upon over two decades of experience integrating Medicare claims and mandatory assessments in NHs across the country, including those pertaining to MA members, this study will empirically determine whether a diagnosis of ADRD constitutes a heretofore unrecognized disparity?that is, does it reduce access to high-quality NH care? We will also test whether alternative payment models that hold providers accountable for patients? clinical care and costs mitigates this effect. Understanding barriers to high-quality NH care is essential to formulating national policies regarding the future long term care needs of patients with ADRD. This project will provide new data that will inform policy makers on how to optimize care for this vulnerable population.
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