Major health system transformations, including the emergence of provider networks responding to Medicare?s value-based payment policies instituted under the Affordable Care Act, are poised to collide with the demography of aging and the rapid rise in the number of persons with Alzheimer?s disease and related dementias (ADRD), the majority of whom will require formal post-acute and long term care. Those with ADRD present special challenges to our current fragmented health care system, which is built upon multiple transitions across care settings and providers. Although the ADRD population is expected to triple by 2050, many recent policy changes aim to maximize the value of care for the ?average? patient, without specific consideration of their consequences for high-cost, high-need populations, such as those with ADRD. This proposed Program Project, Alzheimer's Disease and Related Disorders Treatment and Outcomes in America: Changing Policies and Systems, focuses on how this vulnerable population fares in the face of changing Medicare policies and the increasing use of alternative payment models. Building on two decades of research, the Brown University Center for Gerontology and Health Care Research, in conjunction with colleagues at Dartmouth College, Harvard University, University of Pennsylvania, University of Washington, and Vanderbilt University, propose to study the effects of Medicare policy changes on the care and outcomes experienced by persons with ADRD who interface with home health, skilled nursing, and long-term NH Care. The four projects and three cores all focus on the effects of national Medicare payment and quality regulation policies on the outcomes experienced by persons with ADRD. Projects vary in the populations and care settings included as well as the particular policies studied. Project 1 seeks to determine whether ADRD constitutes a disparity in access to high-quality post-acute nursing care and whether alternative payment models that incentivize greater continuity reduce this disparity, resulting in improved outcomes. Project 2 seeks to understand how ACOs? approach to care delivery impacts the experience and outcomes of vulnerable older persons with advanced dementia. Project 3 evaluates the impact of Medicare Advantage on the outcomes for ADRD patients using home health, SNF, or end-of-life care in a nursing home. Finally, Project 4 examines the intended and unintended consequences of federal policies designed to reduce the use of antipsychotic drugs on the outcomes experienced by persons with ADRD residing in NHs, assisted living, and in the community. All projects rely upon the administrative structure provided by Core A and the methodological innovation of cross- temporal matching and the well-established linked data infrastructure provided by Core C, while Core B aims to solicit and select carefully crafted pilots of intervention studies focused on improving care for ADRD patients that may become full-scale pragmatic cluster randomized trials using extant data resources.
This Program Project proposal seeks to understand how the high-need ADRD patients at various stages of disease progression fare under alternative payment and regulatory structures. To the extent that policies that are applicable to the overall Medicare population do not have unintended consequences in this sub-population of growing importance, we can feel comfortable pushing for continued expansion of current public policy. On the other hand, if new payment models aren?t able to integrate the special needs of persons with ADRD, they may be disadvantaged, with less access to higher quality services that will improve the care received and outcomes experienced.
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