Providing managed care may result in less burdensome and less costly care for nursing home residents with advanced dementia, according to a study.
As published Sept. 23 on the website of JAMA Internal Medicine, researchers analyzed data from 291 nursing home residents with advanced dementia, comparing those who were covered by managed care insurance to those enrolled in traditional fee-for-service Medicare insurance.
Most of these residents are dually eligible for traditional Medicare, which pays for hospital care and physician services on a fee-for-service basis, and Medicaid, which pays nursing homes for daily room, board and nursing care. Because nursing homes do not receive higher reimbursement to manage acutely ill long-term care residents on-site, they have an incentive to transfer these residents to the hospital, temporarily shifting the cost of care from Medicaid to Medicare.
In contrast, managed care programs combine Medicare and Medicaid costs for dual-eligible nursing home residents.
Under managed care, the fiscal incentive for hospitalizing acutely ill nursing home residents with end-stage dementia goes away, study co-author Susan L. Mitchell, MD, MPH, a senior scientist at the Harvard Medical School-affiliated Institute for Aging Research at Hebrew SeniorLife in Boston, said in a news release. Wed like policymakers to understand that this is an example of how a change in the system can lead to less burdensome, more affordable care.
The researchers tracked nursing home residents at 22 facilities in the Boston area, and found managed-care residents who had more primary-care visits, predominantly from nurse practitioners were more likely to have a do-not-hospitalize order in place (63.7% for managed-care residents vs. 50.9% for fee-for-service residents).
These residents also had fewer hospital transfers for acute illness than those in traditional Medicare insurance (3.8% vs. 15.7%). In addition, they had more primary care visits per days (4.8 vs. 4.2) and more nurse practitioner visits (3.0 vs. 0.8). Findings also suggested managed-care residents might have been more likely to enter hospice, and family members might have been more satisfied with overall care at the nursing home.
We found no appreciable difference in survival outcomes between the managed care and fee-for-service groups, Keith S. Goldfeld, DrPH, the studys lead author and an instructor in biostatistics at New York University School of Medicine in New York City, said in the news release. Comfort and treatment outcomes also did not differ significantly.
Nursing home reimbursement policies are among the factors that lead to more aggressive care, according to Goldfeld.
If the payment structure is set up in a way that doesnt benefit the provider to hospitalize residents when they get sick by temporarily shifting costs, the research suggests that you may have equal or even improved outcomes, Goldfeld said.
The investigators also said this research should prompt families to consider opting for managed care or nurse practitioner-based insurance programs for their loved ones with advanced dementia who are in nursing homes.
Researchers with Harvard Medical School and Beth Israel Deaconess Medical Center in Boston contributed to the study.
Study abstract: http://archinte.jamanetwork.com/article.aspx?articleid=1740697