Total and Post-Discharge 30-day Episode Payments for Beneficiaries with Alzheimer’s and Dementia

Objective:There has been a paucity of evidence for post-discharge cost and utilization of healthcare services for older adults with Alzheimer’s and dementia (AD) with Medicare Managed Care or Medicare Fee-For-Service (FFS) beneficiaries following a broad set of surgical procedures. We hypothesized that patients with AD would have higher utilization and costs across patient care settings attributable to their condition. After controlling for clinically relevant factors contributing to selection bias, we sought to quantify the incremental episode payments associated with AD compared to those without AD. The overarching goal of this study is to identify the most effective post-discharge process for patients with AD.

Study Population: We utilized administrative claims data between January 2012 and June 2017 from the Michigan Value Collaborative (MVC), a Blue Cross Blue Shield of Michigan (BCSBM) Collaborative Quality Initiative (CQI) including BCBSM PPO and Medicare FFS patient population across 31 different medical and surgical services for 77 hospitals in Michigan. We identified all patients with AD with any evidence of a diagnosis code throughout their enrollment during the study period using International Classification of Diseases (ICD-9-CM, ICD-10-CM) codes.

Methods:Using the Medicare Fee Schedule to perform price standardization, 30-day episode payments were divided into various components based on patient care setting and claim type: post-acute care, professional, index facility, readmission, and total payments. Post-acute care includes skilled nursing facility admissions, inpatient/outpatient rehabilitation, emergency department (ED) visits, home health services, and other outpatient visits. All payments were risk adjusted using multivariable logistic regression using Hierarchical Condition Categories, age, gender, insurance type, and prior 6 month payments. To account for potential skew in the standardized, risk adjusted payment distribution, payment winsorization was performed at the 99^thand 1^stpercentiles. Controlling for selection bias, we performed propensity score matching at a caliper of 0.001 without replacement adjusting for all surgical service lines, HCCs, insurance type (BCBSM-PPO vs. Medicare FFS), and age at the time of surgery. Sensitivity analysis via varying caliper at 0.05 was also performed. Pre and post propensity matched differences in the aforementioned episode payments were examined using standardized mean differences.

Results:There were noteworthy differences in 30-day total episode payment as well as post-acute care and readmission episode payments. Adjusted episode payments for patients with AD were substantially higher compared to those without evidence of disease ($22,374 vs. $19,593; 95% CI Difference: ($2,656, $2,906)). Post-acute care and readmission payments were also substantially higher among AD patients ($4,548 vs. $3,289; 95% CI Difference: ($1,204, $1,314) and ($1,807 vs $1,186; 95% CI Difference: $574, $670), respectively. There were slight differences in the index surgical payments ($12,799 vs. $12,418; 95% CI Difference: $380-$445).

Conclusion:While surgical costs do not differ significantly between AD and other patients, post-operative episode costs are notably higher for patients with AD. There is strong evidence to suggest that resource intensity and utilization in the postoperative period for AD patients should require further examination. Proper post-operative management of AD patients could improve health and well-beings of adults with AD and reduce the financial burden.