OTHER PROJECT INFORMATION – Project Summary/Abstract Project 5 – Effects of Nursing Home Payment on Patient-Centered Outcomes for Older Adults and People with ADRD Nursing homes provide care to millions of older adults annually, half of whom have Alzheimer’s disease and related dementias (ADRD). Yet many homes are unable to deliver high-quality care, putting patients’ health at risk. One potential policy to address inadequate quality and safety is to raise payment rates for these facilities, thereby encouraging facilities to employ more resources and treat more patients, for instance through increased nurse staffing. This project takes advantage of 2010 and 2019 reforms that overhauled Medicare’s skilled nursing facility (SNF) payment system, changing the payments for thousands of facilities (homes) by 5% or more. The project will leverage these reforms as natural experiments to study the relationship between payment rates and nursing home access and quality. Our rigorous empirical strategy, already validated in a study on hospital payment, uses a simulation approach to predict each nursing home’s change in payment rates from each reform. The method processes pre-reform patients under post-reform payment rules and then uses instrumental variables differences-in-differences models to assess the impacts of payment rates on patient-centered outcomes, tracked in detailed assessment and claims data. Through these data, we can measure direct effects on Medicare patients as well as indirect effects on long-stay Medicaid and private-pay patients. The project will show how SNF payment rates affect access to care and patient-centered outcomes in Medicare; measure effects on key quality of life outcomes such as depression, behavior, and cognitive function; analyze the mechanisms driving these effects by assessing impacts on resources for care, such as nurse staffing; study patient outcomes due to shocks such as seasonal influenza to better understand whether payment contributes to SNF preparedness for infectious disease outbreaks, including COVID-19; consider the “spillover” effects of Medicare payment on long-stay patients who were not the target of the reform; and consider how payment affects racial/ethnic and other socioeconomic disparities. The project adds to the P01 research plan a fifth major influence on healthcare – provider payment rates – and in an additional care setting – nursing homes. It considers the effects of policy in a crucial setting where care is delivered to people living with ADRD and an important potential cause of disparities in access and outcomes.

OTHER PROJECT INFORMATION – Project Narrative Nursing homes are key sources of care for millions of older adults, especially those with dementia, but many facilities are unable to consistently deliver high-quality care for these vulnerable patients. To explore the role of payment rates as a tool to address these gaps in quality, this project leverages two recent Medicare nursing home payment reforms as natural experiments. We consider the effects of payment on the quality and safety of care for skilled nursing patients, the mechanisms like staffing that drive these effects, “spillover” effects onto long-stay patients, and the implications of payment changes for disparities in care access and quality. These results will show the benefits and potential unintended consequences of payment reforms and guide future efforts to improve healthcare quality and value for people with dementia and other older adults.