Evaluating The Accuracy Of Medicare Risk Adjustment For Alzheimer’s Disease And Related Dementias

Promise and peril of claims-based dementia ascertainment in causal inference

“…It is also important to consider that claims-based definitions of ADRD are often validated against information within the electronic health record, which is subject to similar sources of information bias 20. As with administrative claims, hierarchical factors at the level of the patient, provider and insurer influence the likelihood that cognitive symptoms and assessments are documented 21. This results in the common validation of claims-based ADRD definitions against reference standards that may non-randomly misclassify clinical status 21.…”

“…As with administrative claims, hierarchical factors at the level of the patient, provider and insurer influence the likelihood that cognitive symptoms and assessments are documented 21. This results in the common validation of claims-based ADRD definitions against reference standards that may non-randomly misclassify clinical status 21. Therefore, the performance characteristics of clams-based ADRD definitions should be interpreted in the context of reference standard limitations and researchers should acknowledge and address the direction and impact of bias pertinent to their research question.…”

“…One major factor includes varying reimbursement incentives, which have occurred in the US Medicare population 22. Enhancing the reimbursement tied to ADRD would be expected to increase incident and prevalent cases within administrative data 21. Two such changes occurred in 2014 and 2020 when CMS first eliminated additional financial reimbursement for beneficiaries with both complicated and uncomplicated dementias and then reintroduced it 23.…”

Trends in Incident Dementia Diagnosis Before and After Medicare Risk Adjustment

“…Medicare reintroduced risk adjustment for Alzheimer disease and related dementias (ADRD) to its Medicare Advantage (MA) plan payments in 2020, which provides incentive to improve dementia detection and reduce missed diagnoses but also renews concerns about diagnostic upcoding 1 for over 30 million MA beneficiaries. We assessed annual trends in incident ADRD diagnosis for all beneficiaries in MA and compared them with trends in traditional Medicare (TM) from 2016 through 2020.…”

Promising Administrative Measures of Heart Failure and Future Directions

“…2,3 Because the accuracy of administrative diagnosis codes may vary with clinical and policy conventions, their performance characteristics require ongoing evaluation. 4 While clinical databases are not well-suited to describe national trends, national claims often lack the granularity to describe clinical and epidemiologic trends accurately. This challenge is common to other diseases and syndromes.…”