Mechanisms for Organizational Behavior Change to Address the Needs of People Living with Alzheimer's Disease and Related Dementias Proceedings of a Workshop (2022) / Chapter Skim
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4 Transforming the Role of Payment System Incentives to Improve Quality
4 Transforming the Role of Payment System Incentives to Improve Quality
Pages 33-46
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From page 33... ...
The Office of Behavioral Health, Disability, and Aging Policy coordinates dementia care, research, and policy and oversees implementation of the National Alzheimer's Project Act, which maintains the National Plan to Address Alzheimer's Disease. Sherry said that two-thirds of people living with ADRD live at home and receive care and services in their home from home health workers and unpaid family caregivers, as well as care in ambulatory care (outpatient)
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From page 34... ...
For example, Medicaid covers long-term nursing home care, whereas Medicare, which typically has a higher reimbursement rate for care, covers hospital and post-acute care. This creates a condition in which nursing homes are incentivized to send long-term residents to the hospital in order to receive Medicare's higher reimbursement rate for care provided at the nursing home upon the patient's return to the nursing home because that can be categorized as post-acute care.
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From page 35... ...
. The combined effect of the payment landscape and the clinical features of ADRD leads to a substantial reliance on unpaid caregivers, high out-of-pocket spending, and increased reliance on Medicaid-financed nursing home care.
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From page 36... ...
Hospice Benefit SOURCE: Presented by Tisamarie Sherry on May 23, 2022 the workshop Mechanisms for Organizational Behavior Change to Address the Needs of People Living with Alzheimer's Disease and Related Dementias. based Incentive Payment System and value-based incentives that coordinate care across settings, such as the Medicare Shared Savings Program.
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From page 37... ...
Sherry noted that reforming the payment system is not sufficient to improve quality of care for people with ADRD. While the PACE model contains many of the desired elements for delivery of quality ADRD care, its uptake has been limited in part by high regulatory barriers.
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From page 38... ...
Organizational models that promote high-quality ADRD care should incorporate support for caregivers, medication management, self-management, psychosocial interventions, and longitudinality. Navathe noted that salience is a challenge for population health payment models.
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This leaves funding for state Medicaid vulnerable to political pressure, and people with Alzheimer's and their families are usually not the most politically empowered constituents of the state budget offices. Vladeck noted that there are ways to improve quality of care without financial incentives.
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A reworked system needs to accommodate the three main contexts in which people with ADRD receive care and services: hospitals and primary care practices, nursing homes, and home care. Primary care physicians may require incentives to improve initial assessment of patients with possible cognitive impairment.
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From page 41... ...
Also, there are considerable disparities within dementia care based on a patient's ability to pay. She added that personal long-term planning frequently cannot compensate for the structural problems within the public insurance systems related to financing ADRD care for older adults.
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From page 42... ...
Additional necessary components that Largent cited include reimbursement for social workers; increased access to respite care; collaborative ADRD care models; and ADRD care navigators, particularly to support care transitions. She added that health care facilities, including hospitals, should revise visitor policies to recognize that caregivers are not typical visitors, they are part of the patient care workforce and often serve as "the extended mind" of a person living with ADRD.
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From page 43... ...
Vladeck noted that if a person with ADRD requires constant care that cannot be provided by an unpaid caregiver, care in a nursing home is less expensive than paying for constant home care. He suggested a possible approach could be an incentive-based payment system that would provide a percentage of the cost of nursing home care to families caring for Medicaid
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From page 44... ...
Institutionalization and De-institutionalization Challenges Hollmann and Vladeck briefly discussed the roles of institutionalization and deinstitutionalization in care models for patients with ADRD. Hollmann suggested modeling the effects of transferring financing from institutional care to home care for people with ADRD.
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From page 45... ...
Scaling Frank noted that several effective care models for people with ADRD described by speakers were examples of "expensive boutique operations," and asked the group to discuss the essential components of those expensive small models that could be scaled up to develop a workable and effective largescale model. Vladeck suggested developing institutional models and creating regionally based centers that could translate the lessons from smaller-scale programs into operational practices and lobby for the adjustments in payment policy needed to make these models more widely available.
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From page 46... ...
Resources for Information About Quality Fulmer recommended four resources that represent opportunities to enhance the evidence base regarding quality of care for people living with ADRD and support for their caregivers: • The Family Caregiver Alliance,5 • HRSA's Geriatrics Workforce Enhancement Program,6 • The Veterans Administration,7 and • The Administration for Community Living.8 5 See https://www.caregiver.org (accessed July 16, 2022)
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