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Original Investigation
December 21, 2018

Health Care Utilization and Cost Outcomes of a Comprehensive Dementia Care Program for Medicare Beneficiaries

Author Affiliations
  • 1Reynolds Department of Geriatric Medicine at the University of Oklahoma Health Sciences Center, Oklahoma City
  • 2NORC at the University of Chicago, Bethesda, Maryland
  • 3Centers for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation, Baltimore, Maryland
  • 4Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
  • 5Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
JAMA Intern Med. Published online December 21, 2018. doi:10.1001/jamainternmed.2018.5579
Key Points

Question  What are the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare beneficiaries?

Findings  In a case control study that used a quasiexperimental design to assess the health care utilization of 3249 patients with dementia, those patients in a dementia care program were less likely to be admitted to a long-term care facility than patients in a propensity score–matched control group. After accounting for implementation costs, the program was cost neutral.

Meaning  Comprehensive dementia care programs may help more patients stay in community-based settings and was cost neutral.

Abstract

Importance  An estimated 4 to 5 million Americans have Alzheimer disease or another dementia.

Objective  To determine the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare fee-for-service beneficiaries.

Design, Setting, and Participants  In this case-control study, we used a quasiexperimental design to compare health care utilization and costs for 1083 Medicare fee-for-service beneficiaries enrolled in the University of California Los Angeles Health System Alzheimer and Dementia Care program between July 1, 2012, and December 31, 2015, with those of 2166 similar patients with dementia not participating in the program. Patients in the comparison cohort were selected using the zip code of residence as a sampling frame and matched with propensity scores, which included demographic characteristics, comorbidities, and prior-year health care utilization. We used Medicare claims data to compare utilization and cost outcomes for the 2 groups.

Interventions  Patients in the dementia care program were comanaged by nurse practitioners and physicians, and the program consisted of structured needs assessments of patients and their caregivers, creation and implementation of individualized dementia care plans with input from primary care physicians, monitoring and revising care plans, referral to community organizations for dementia-related services and support, and access to a clinician for assistance and advice 24 hours per day, 7 days per week.

Main Outcomes and Measures  Admissions to long-term care facilities; average difference-in-differences per quarter over the 3-year intervention period for all-cause hospitalization, emergency department visits, 30-day hospital readmissions, and total Medicare Parts A and B costs of care. Program costs were included in the cost estimates.

Results  Program participants (n = 382 men, n = 701 women; mean [SD] age, 82.10 [7.90] years; age range 54-101 years) were less likely to be admitted to a long-term care facility (hazard ratio, 0.60; 95% CI, 0.59-0.61) than those not participating in the dementia care program (n = 759 men, n = 1407 women; mean [SD] age, 82.42 [8.50] years; age range, 34-103 years). There were no differences between groups in terms of hospitalizations, emergency department visits, or 30-day readmissions. The total cost of care to Medicare, excluding program costs, was $601 less per patient per quarter (95% CI, −$1198 to −$5). After accounting for the estimated program costs of $317 per patient per quarter, the program was cost neutral for Medicare, with an estimated net cost of −$284 (95% CI, −$881 to $312) per program participant per quarter.

Conclusions and Relevance  Comprehensive dementia care may reduce the number of admissions to long-term care facilities, and depending on program costs, may be cost neutral or cost saving. Wider implementation of such programs may help people with dementia stay in their communities.

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