Implications of Medicare Advantage for Patients With Alzheimer Disease and Related Dementias | Dementia and Cognitive Impairment | JAMA Network Open | JAMA Network
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Invited Commentary
Health Policy
March 30, 2020

Implications of Medicare Advantage for Patients With Alzheimer Disease and Related Dementias

Author Affiliations
  • 1Providence VAMC, Center of Innovation for Long Term Services and Supports, Providence, Rhode Island
  • 2School of Public Health, Brown University, Providence, Rhode Island
  • 3Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
JAMA Netw Open. 2020;3(3):e201853. doi:10.1001/jamanetworkopen.2020.1853

The care of patients with Alzheimer disease and related dementias (ADRD) is complex and costly.1,2 The number of US individuals with ADRD is growing rapidly and is estimated to increase from 4.5 million in 2010 to 13.8 million in 2050, with mean per-person health care costs often 3 times greater for patients with ADRD than for those without ADRD.3 Patients with ADRD and their caregivers often report that their care is uncoordinated and fragmented, and evidence suggests that burdensome transitions are frequent.2 In the end, these transitions are often inefficient and only serve to cost more health care dollars without enhancing quality.

The work by Park and colleagues4 highlights the differences in health care utilization for patients with ADRD enrolled in traditional Medicare (TM) fee-for-service plans vs those who are enrolled in capitated Medicare Advantage (MA) plans. The proportion of Medicare beneficiaries enrolled in MA plans increased from 10.2 million in 2009 to 18.2 million in 2017.5 Some policy observers contend that capitated payments to MA plans provide strong incentives to provide higher-value care and allow flexibility for plans to invest in care coordination efforts and enhanced chronic disease management, such as social determinants of health spending. In contrast, critics of MA have expressed concerns that capitated payments may spur plans to restrict access to care and may, in fact, lead to the disenrollment of beneficiaries with complex health care needs, such as those with ADRD. Unfortunately, few studies have compared the quality and outcomes of care in Medicare Advantage and TM for patients with complex health conditions.

The study by Park et al4 was conducted using longitudinal data between 2010 and 2016, and the findings suggest that patients with ADRD enrolled in MA plans had 22.3 fewer visits to a medical provider and 2.3 fewer visits to the outpatient hospital setting than those enrolled in TM fee-for-service plans. Despite the reduced care, the analyses failed to detect statistically significant differences in health care status or care satisfaction between MA and TM beneficiaries, although the estimates could not exclude meaningful differences in these measures between the 2 populations. The authors, therefore, speculate that MA may have achieved cost savings through better coordination of care without jeopardizing health care quality.

Although this theory is possible, there are several limitations to this work4 that merit discussion. The authors rightly point out that MA plans have long had a history of skimming the cream off the top, offering incentives that attract healthier populations than those enrolled in TM plans. Although the investigators identified no differences in care satisfaction between those enrolled in MA vs TM, they could not account for those patients who potentially left, or were coerced to leave, MA plans to reenroll in TM. This is important, because prior work6,7 has shown that MA beneficiaries who are dually eligible for Medicaid or who receive skilled nursing facility or home health care have high rates of disenrollment in the following year.

It Is also important to note that the population with ADRD is clinically heterogeneous, and patients with dementia can have a wide range of cognitive and functional impairments that range from those who are completely independent to profound disability. Park et al4 did attempt to control for this variability by including a measure of function in the form of an activities of daily living metric. Nevertheless, this functional scale is unlikely to account fully for the differences in clinical severity between TM and MA beneficiaries with ADRD. The analysis by Park et al4 identified substantially fewer functional limitations in the MA population, perhaps explaining why those patients had fewer health care visits.

The study by Park et al4 of patients with ADRD suggests that those enrolled in MA plans received fewer health services compared with patients enrolled in TM. These differences in care could reflect selection of a less-impaired slice of the population with ADRD, differential disenrollment of high-need patients with ADRD out of MA plans, restricted access to effective care, or more-efficient health care delivery. More research will need to be done to fully understand the implications of managed care for patients with ADRD and other complex medical conditions.

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Article Information

Published: March 30, 2020. doi:10.1001/jamanetworkopen.2020.1853

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Dosa DM et al. JAMA Network Open.

Corresponding Author: David M. Dosa, MD, MPH, Department of Medicine, Warren Alpert Medical School of Brown University, 121 S Main St, Box G-S121-6, Providence, RI 02912 (david_dosa@brown.edu).

Conflict of Interest Disclosures: Dr Dosa reported receiving grants from the US Department of Veterans Affairs Health Services Research and Development and from the National Institute on Aging during the conduct of the study. Drs Trivedi and Mor reported receiving grants from the National Institute on Aging outside the submitted work. No other disclosures were reported.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

References
1.
Hurd  MD, Martorell  P, Delavande  A, Mullen  KJ, Langa  KM.  Monetary costs of dementia in the United States.  N Engl J Med. 2013;368(14):1326-1334. doi:10.1056/NEJMsa1204629PubMedGoogle ScholarCrossref
2.
Teno  JM, Gozalo  P, Trivedi  AN,  et al.  Site of death, place of care, and health care transitions among US Medicare beneficiaries, 2000-2015.  JAMA. 2018;320(3):264-271. doi:10.1001/jama.2018.8981PubMedGoogle ScholarCrossref
3.
Hebert  LE, Scherr  PA, Bienias  JL, Bennett  DA, Evans  DA.  Alzheimer disease in the US population: prevalence estimates using the 2000 census.  Arch Neurol. 2003;60(8):1119-1122. doi:10.1001/archneur.60.8.1119PubMedGoogle ScholarCrossref
4.
Park  S, White  L, Fishman  P, Larson  EB, Coe  NB.  Health care utilization, care satisfaction, and health status for Medicare Advantage and traditional Medicare beneficiaries with and without Alzheimer disease and related dementias.  JAMA Netw Open. 2020;3(3):e201809. doi:10.1001/jamanetworkopen.2020.1809Google Scholar
5.
Skopec  L, Zuckerman  S, Allen  EG, Aarons  J. Why did Medicare Advantage enrollment grow as payment pressure increased? examining the role of market and demographic changes. Published April 2019. Accessed February 10, 2020. https://www.urban.org/sites/default/files/publication/100152/why_did_medicare_advantage_enrollment_grow_as_payment_pressure_increased_1.pdf
6.
Goldberg  EM, Trivedi  AN, Mor  V, Jung  HY, Rahman  M.  Favorable risk selection in Medicare Advantage: trends in mortality and plan exits among nursing home beneficiaries.  Med Care Res Rev. 2017;74(6):736-749. doi:10.1177/1077558716662565PubMedGoogle ScholarCrossref
7.
Li  Q, Keohane  LM, Thomas  K, Lee  Y, Trivedi  AN.  Association of cost sharing with use of home health services among Medicare Advantage enrollees.  JAMA Intern Med. 2017;177(7):1012-1018. doi:10.1001/jamainternmed.2017.1058PubMedGoogle ScholarCrossref
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