Comparing the care experiences of Medicare Advantage beneficiaries with and without Alzheimer's disease and related dementias

Top-Rated Health Care and Ease of Access to Medications Linked to Lower Medicare and ADRD Costs

IMPORTANCE

Little is known about the extent to which patient self-perception of care experience is associated with costs, especially for people with Alzheimer disease and related dementias (ADRD).

OBJECTIVE

This study explores the relationship between self-reported quality measures and Medicare costs and examines whether the ease of obtaining prescribed medications is associated with reduced overall Medicare costs, focusing on Medicare beneficiaries with ADRD.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, Medicare Beneficiary Summary File data from 2018, 2019, and 2021 were linked to the Medicare Consumer Assessment of Health Care Providers and Systems (CAHPS) Survey using beneficiary IDs. The study sample included community-dwelling Medicare fee-for-service beneficiaries.

EXPOSURES

Five quality measures were used as key exposure variables: (1) beneficiary's rating on health care; (2) ease of getting care/tests/treatment through the health plan; (3) whether the doctor always explained, listened, respected; and spent enough time with the patient; (4) ease of obtaining prescribed medications; and (5) whether doctor always talked about all the prescription medicines the beneficiary was taking.

MAIN OUTCOME AND MEASURE

Annual total Medicare payments per person.

RESULTS

The study included 230,617 Medicare fee-for-service beneficiaries aged 65 and older, including 16,452 beneficiaries with ADRD. Among the total beneficiaries, 53% were females (vs. 56% of ADRD beneficiaries), with a mean (SD) age of 75.8 (SD 7.27) years [vs. 82.5 (SD 7.97) years for ADRD beneficiaries]. Fully adjusted analyses showed significant negative associations between quality measures and total per-capita payments, with more pronounced cost reductions among patients with ADRD. Specifically, patients with ADRD who reported it was always easy to get care had reductions of $1,922.0 (95% CI, -$3304.8 to -$539.2), while those who reported it was always easy to get prescribed medications had reductions of $2964.5 (95% CI, -$4518.8 to -$1410.1). In addition, beneficiaries who reported that doctors always discussed the medicines experienced cost reductions of $2299.7 (95% CI, -$3800.5 to -$799.0) in medicare costs.

CONCLUSION AND RELEVANCE

Our findings suggest that high-quality care is not necessarily associated with high costs. Meanwhile, focusing on the ease of access to needed care, obtaining prescription drugs, and effective communication about medication is critical in improving care quality while reducing costs.

Patterns of national emergency department utilization by fee-for-service Medicare beneficiaries with dementia

BACKGROUND

Individuals with Alzheimer's disease and related dementias (ADRD) often face high acute care clinical utilization and costs with unclear benefits in survival or quality of life. The emergency department (ED) is frequently the site of pivotal decisions in these acute care episodes. This study uses national Medicare data to explore this population's ED utilization.

METHODS

Retrospective cohort study of persons aged ≥66 years enrolled in traditional Medicare with a Chronic Condition Warehouse diagnosis of dementia. Primary 1-year outcome measures included ED visits with and without hospitalization, ED visits per 100 days alive, and health-care costs. A multivariate random effects regression model (clustered by county of residence), adjusted for sociodemographics and comorbidities, examined how place of care on January 1, 2018, was associated with subsequent ED utilization.

RESULTS

In 2018, 2,680,006 ADRD traditional Medicare patients (mean age 82.9, 64.2% female, 9.4% Black, 6.2% Hispanic) experienced a total of 3,234,767 ED visits. Over half (52.2%) of the cohort experienced one ED visit, 15.5% experienced three or more, and 37.1% of ED visits resulted in hospitalization. Compared with ADRD patients residing at home without services, the marginal difference in ED visits per 100 days alive varied by location of care. Highest differences were observed for those with hospitalizations (0.48 visits per 100 days alive, 95% confidence interval [CI] 0.47-0.49), skilled nursing facility (rehab/skilled nursing facility [SNF]) stays (0.27, 95% CI 0.27-0.28), home health stays (0.25, 95% CI 0.25-0.26), or observation stays (0.82, 95% CI 0.77-0.87). Similar patterns were observed with ED use without hospitalization and health-care costs.

CONCLUSIONS

Persons with ADRD frequently use the ED-particularly those with recent hospitalizations, rehab/SNF stays, or home health use-and may benefit from targeted interventions during or before the ED encounters to reduce avoidable utilization and ensure goal-concordant care.

Medicare Advantage enrollment and outcomes of post-acute nursing home care among patients with dementia

Enrollment in Medicare Advantage (MA) has been rapidly growing. We examined whether MA enrollment affects the outcomes of post-acute nursing home care among patients with Alzheimer's disease and related dementias (ADRD). We exploited year-to-year changes in MA penetration rates within counties from 2012 through 2019. After adjusting for patient-level characteristics and county fixed effects, we found that MA enrollment was not associated with days spent at home, nursing home days, likelihood of becoming a long-stay resident, hospital days, hospital readmission, or 1-year mortality. There was a modest increase in successful discharge to the community by 0.73 percentage points (relative increase of 2.4%) associated with a 10-percentage-point increase in MA enrollment. The results are consistent among racial/ethnic subgroups and dual-eligible patients. These findings suggest an imperative need to monitor and improve quality of managed care among enrollees with ADRD.

Ready or Not: A Conceptual Model of Organizational Readiness for Embedded Pragmatic Dementia Research

The National Institute on Aging Alzheimer's Disease/Alzheimer's Disease and Related Dementias Research Implementation Milestones emphasize the need for implementation research that maximizes up-take and scale-up of evidence-based dementia care practices across settings, diverse populations, and disease trajectories. Organizational readiness for implementation is a salient consideration when planning and conducting embedded pragmatic trials, in which interventions are implemented by provider staff. The current article examines the conceptual and theoretical underpinnings of organizational readiness for implementation and the operationalization of this construct. We offer a preliminary conceptual model for explicating and measuring organizational readiness and describe the unique characteristics and demands of implementing evidence-based interventions targeting persons with dementia and/or their care partners. [Research in Gerontological Nursing, 17(3), 149-160.].

Functional and clinical needs of older hospice enrollees with coexisting dementia

BACKGROUND

The Medicare Hospice Benefit increasingly serves people dying with dementia. We sought to understand characteristics, hospice use patterns, and last-month-of-life care quality ratings among hospice enrollees with dementia coexisting with another terminal illness as compared to enrollees with a principal hospice diagnosis of dementia, and enrollees with no dementia.

METHODS

We conducted a pooled cross-sectional study among decedent Medicare beneficiaries age 70+ using longitudinal data from the National Health and Aging Trends Study (NHATS) (last interview before death; after-death proxy interview) linked to Medicare hospice claims (2011-2017). We used unadjusted and adjusted regression analyses to compare characteristics of hospice enrollees with coexisting dementia to two groups: (1) enrollees with a principal dementia diagnosis, and (2) enrollees with no dementia.

RESULTS

Among 1105 decedent hospice enrollees age 70+, 40% had coexisting dementia, 16% had a principal diagnosis of dementia, and 44% had no dementia. In adjusted analyses, enrollees with coexisting dementia had high rates of needing help with 3-6 activities of daily living, similar to enrollees with principal dementia (62% vs. 67%). Enrollees with coexisting dementia had high clinical needs, similar to those with no dementia, for example, 63% versus 61% had bothersome pain. Care quality was worse for enrollees with coexisting dementia versus principal dementia (e.g., 61% vs. 79% had anxiety/sadness managed) and similar to those with no dementia. Enrollees with coexisting dementia had similar hospice use patterns as those with principal diagnoses and higher rates of problematic use patterns compared to those with no dementia (e.g., 16% vs. 10% live disenrollment, p = 0.004).

CONCLUSIONS

People with coexisting dementia have functional needs comparable to enrollees with principal diagnoses of dementia, and clinical needs comparable to enrollees with no dementia. Changes to hospice care models and policy may be needed to ensure appropriate dementia care.

Variations in Medicare Advantage Switching Rates Among African American and Hispanic Medicare Beneficiaries With Alzheimer's Disease and Related Dementias, by Sex and Dual Eligibility

OBJECTIVES

The objective of this study was to identify rates of switching to Medicare Advantage (MA) among fee-for-service (FFS) Medicare beneficiaries with Alzheimer's disease and related dementias (ADRD) by race/ethnicity and whether these rates vary by sex and dual-eligibility status for Medicare and Medicaid.

METHODS

Data came from the Medicare Master Beneficiary Summary File from 2017 to 2018. The outcome of interest for this study was switching from FFS to MA during any month in 2018. The primary independent variable was race/ethnicity including non-Hispanic White, non-Hispanic African American, and Hispanic beneficiaries. Two interaction terms among race/ethnicity and dual eligibility, and race/ethnicity and sex were included. The model adjusted for age, year of ADRD diagnosis, the number of chronic/disabling conditions, total health care costs, and ZIP code fixed effects.

RESULTS

The study included 2,284,175 FFS Medicare beneficiaries with an ADRD diagnosis in 2017. Among dual-eligible beneficiaries, adjusted rates of switching were higher among African American (1.91 percentage points [p.p.], 95% confidence interval [CI]: 1.68-2.15) and Hispanic beneficiaries (1.36 p.p., 95% CI: 1.07-1.64) compared to non-Hispanic White beneficiaries. Among males, adjusted rates were higher among African American (3.28 p.p., 95% CI: 2.97-3.59) and Hispanic beneficiaries (2.14 p.p., 95% CI: 1.86-2.41) compared to non-Hispanic White beneficiaries.

DISCUSSION

Among persons with ADRD, African American and Hispanic beneficiaries are more likely than White beneficiaries to switch from FFS to MA. This finding underscores the need to monitor the quality and equity of access and care for these populations.