Policymakers should consider incentivizing nursing homes to take patients with Alzheimer’s disease and related dementias (ARDR) argue the authors of a new study that finds such patients currently are more likely to enter low-quality facilities after a hospital stay.
Patients with dementia were more frequently admitted to larger skilled nursing facilities, for-profit facilities and those with low star ratings compared to patients without dementia, reported researchers from Brown University and the University of Pennsylvania.
In a three-year study of more than 2 million Medicare beneficiaries, researchers also found those with Alzheimer’s or similar diagnoses were less likely to enter hospital-based facilities and received less overall postacute care as indicated by the level of Medicare financing.
They said a combination of regulatory and payment changes are “badly needed” to improve the care process and support direct care staff working with dementia patients.
Investigators pinpointed the intense caregiving needs of dementia patients as one reason for limited access to highly rated facilities. But they also blamed the disparity on a payment system that creates a preference for short-stay patients.
“SNF managers may believe Medicare reimbursement inadequately considers patients’ behavioral health,” wrote authors Cyrus M. Kosar, PhD,, and Vincent Mor, PhD (pictured above), both of Brown University, and UPenn’s Rachel M. Werner, MD, PhD. They noted that facilities may not be able to return such patients home before their Medicare benefits run out at 100 days, a factor that cuts into revenues and runs counter to a push by payers to reduce lengths of stay.
“If patients with ADRD have a lower likelihood of leaving the nursing home after their postacute care needs are met, then nursing homes may avoid admitting them to prevent possible future shortfalls in revenue,” they added.
The study used data gathered under the previous Resource Utilization Groups payment system, which was widely viewed as rewarding providers’ for higher therapy use. Many patients with dementia diagnoses cannot fully participate in therapy, and RUGS did not consider their behavioral complexity, the researchers wrote.
But even under the new Patient Driven Payment Model, experts noted, the Centers for Medicare & Medicaid Services did not explicitly increase payment for behavioral issues, though some providers have been better able to capture reimbursement for common comorbidities.
“Improving nursing home quality for patients with ADRD likely requires more targeted efforts and is essential given research showing improved outcomes for individuals discharged to higher rated SNFs,” the authors reported in JAMA Network Open on Wednesday. “Policies that recognize the interrelationship between postacute and long-term care and specifically address perverse incentives stemming from fragmentation are likely needed to ensure that patients with ADRD receive equitable postacute and long-term care.”
In an accompanying commentary, Peter A. Boling, MD, and Christian Bergman, MD, of the Division of Geriatric Medicine at Virginia Commonwealth University, opined PDPM’s missed opportunity to improve access for dementia patients by increasing reimbursement.
“Daily care of patients with advanced chronic illness and ADRD is arduous. Doing it well requires workers with special personal qualities plus skills that can be taught, but at some cost. Unfortunately, funders and employers undervalue this work, leading to a situation in which vulnerable patients, separated from their families, are too often treated by overextended staff who are not well supported,” they noted. “While the PDPM represents a first step in improving incentives, it would likely be more effective if ADRD were specifically listed in the non-therapy ancillary comorbidity score.”