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

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-indifferences 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.

2020 Alzheimer's disease facts and figures

“…The program was relatively low cost per person, with an average annual cost of $618 ($739 in 2019 dollars) — a nearly 6‐to‐1 return on investment. Another group of researchers, however, found that a dementia care program that used nurse practitioners and physicians to co‐manage patients was cost neutral after taking into account the costs of the program and cost savings due to fewer long‐term care nursing home admissions 585 . However, in a recent systematic review and meta‐analysis of 17 randomized controlled trials from seven different countries aimed at reducing avoidable acute hospital care by persons with dementia, none of the interventions reduced acute hospital use, such as emergency department visits, hospital admissions, or hospital days 586 …”

“…Another approach to bridging the gap is to expand collaborative and coordinated care programs, which rely heavily on non‐specialists. Pilot programs for individuals with dementia have reduced hospital and emergency room visits 502,608 and nursing home placement 585 . In the UCLA Alzheimer's and Dementia Care Program, dementia care management is provided by a nurse practitioner supervised by a primary care physician.…”

“…In the UCLA Alzheimer's and Dementia Care Program, dementia care management is provided by a nurse practitioner supervised by a primary care physician. After one year in the program, 58% of people living with dementia and 63% of their caregivers showed clinical benefit on validated instruments, 508 and the gross savings to Medicare on an annual basis totaled $2,404 per patient per year 585 . A similar collaborative care model in Indiana, the Healthy Aging Brain Center (HABC), resulted in gross savings of $3,474 per patient per year 502 .…”

Variations in Costs of a Collaborative Care Model for Dementia

“…They reported an estimated cost of $95 per dyad/month considering a caseload of 75 . Another program implemented by the University of California, Los Angeles, reported a per dyad‐month cost of $106 . A team of five dementia care managers (with a caseload of 250 dyads), managed by nurse practitioners and physicians, provided in‐person and remote care coordination .…”

“…Some have suggested that payments for collaborative dementia programs need to be restructured altogether, by moving away from fee for service toward a per beneficiary monthly payment that would include a comprehensive range of reimbursable services . It is also important to note that at least two collaborative dementia care programs were shown to be either cost neutral or provide cost savings by means of reducing healthcare utilization costs . That alone should elicit the need to provide better incentives for increasing the uptake of collaborative dementia care models.…”