Medicare Managed Care Programs for Nursing Home Residents with Dementia

A recent study combined data from a prospective cohort study with Medicare claims files to compare patterns of care and quality outcomes between nursing home residents with advanced dementia covered by managed care and individuals covered by traditional fee-for-service Medicare [JAMA Intern Med. doi:10.1001/jamainternmed.2013.10573]. The results suggest that Medicare managed care programs may offer appropriate, less burdensome, and affordable care, particularly for patients at the end of life.

“This study provides novel data suggesting that the model of health care delivery in a nursing home has important effects on the type of care received by individual residents,” said lead author of the study, Keith Goldfeld, DrPH, Instructor, Department of Population Health, School of Medicine, New York University.

Stepping into an opportunity opened up by the passing of the Patient Protection and Affordable Care Act to focus on improving the quality and cost-effectiveness of care, Dr. Goldfeld and colleagues undertook the study to compare a managed care structure with the traditional fee-for-service Medicare for nursing home residents with advanced dementia.

In the study, investigators merged data from the CASCADE (Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life) study with Medicare claims files from February 2003 through December 2010. The CASCADE study is a prospective cohort study in which 323 residents with advanced dementia from 22 Boston-area nursing homes were monitored for 18 months between February 2003 and March 2009. Along with dementia, all residents included in the study were >60 years of age and had a Global Deterioration Scale score of 7.

To compare patterns of care and quality outcomes between managed care Medicare programs and traditional fee-for-service Medicare programs, the investigators evaluated the following outcomes:

• Survival

• Symptoms related to comfort

• Presence of pressure ulcers

• Treatment of pain and dyspnea

• Treatment of pneumonia

• Presence of a do-not-hospitalize order (DNH)

• Hospital transfer for acute illness

• Hospice referral

• Primary care visits

• Family satisfaction with care

A total of 291 residents were included in the study, 133 (45.7%) of whom were enrolled in a managed care plan and 158 (54.3%) enrolled in a traditional fee-for-service Medicare plan. Of the entire cohort, the mean age was 85.5 years, most were female (85.6%), white (89.7%), and 43.6% lived in a special care unit for advanced dementia.

The study found that significantly more residents in managed care programs compared to those in traditional fee-for-service programs were likely to have DNH orders (63.7% vs 50.9%; adjusted odds ratio [OR], 1.9%; 95% confidence interval [CI], 1.1-3.4; P<.05); were less likely to be transferred to the hospital for acute illness (3.8% vs 15.7%; adjusted OR, 0.2; 95% CI, 0.1-0.5; P<.05); had more primary care visits per 90 days (mean 4.8 vs 4.2; adjusted rate ratio 1.3; 95% CI, 1.1-1.6; P<.05); and more nurse practitioner visits (mean 3.0 vs 0.8; adjusted rate ratio, 3.0; 95% CI, 2.2-4.1; P<.05).

Although not significantly different, more residents in manage care programs also were referred to hospice (23.3% vs 18.4%). No differences were found between the 2 cohorts in terms of survival, other treatment outcomes, or comfort. Overall, 276 patients (94.8%) died; 126 (94.7%) were in the managed care group, and 150 (94.9%) were in the fee-for-service group (P=.88).

Based on these results, Dr. Goldfeld emphasized the importance of intensive primary care services saying that these services may be a promising approach to ensuring less burdensome and more affordable care, particularly for residents at the end of life. “Ultimately, it may require a change in the underlying financial structure to institute these changes,” said Dr. Goldfeld.

Limitations of the study highlighted by Dr. Goldfeld included the lack of randomization in the study that disallowed a causal analysis between the observed associations between patient insurance status and outcomes. He also said that it is uncertain whether the results can be generalized to areas other than Boston.