RAND Corporation, Pittsburgh, Pennsylvania.
RAND Corporation, Arlington, Virginia.
JAMA Netw Open. 2023 Jul 3;6(7):e2322520. doi: 10.1001/jamanetworkopen.2023.22520.
New York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care.
To evaluate changes in nursing home use among older adults with dementia following MLTC implementation.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019.
Mandatory MLTC enrollment.
Longitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators.
This sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year).
The findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.
纽约州的医疗补助管理长期护理（MLTC）计划扩大了对家庭和社区为基础服务的获取途径，为有痴呆症的人提供了一种替代疗养院护理的选择。2012 年至 2015 年间，该州为需要 120 天以上社区长期护理的双重医疗保险和医疗补助参保者实施了强制性 MLTC。
评估 MLTC 实施后痴呆症老年人对疗养院使用的变化。
设计、地点和参与者：这项队列研究使用了 2011 年 1 月 1 日至 2019 年 12 月 31 日来自最低数据集和医疗保险管理数据的纵向数据。研究样本包括纽约州 65 岁及以上患有痴呆症的医疗保险受益人。由于研究前期间的数据不足，排除了纽约市居民。数据分析于 2011 年 1 月 1 日至 2019 年 12 月 31 日进行。
强制性 MLTC 登记。
使用纵向模型评估了在该州 13 个地区分阶段实施 MLTC 后，每年在疗养院使用的天数的变化。估计了两种模型：（1）用于给定年份任何疗养院使用的逻辑回归模型，以及（2）有任何疗养院使用的情况下，疗养院使用总天数的线性回归模型，条件是有任何疗养院使用。模型包括指定为 MLTC 实施前或实施后年数的年度事件时间指标。为了捕捉 MLTC 对双重参保者相对于非双重医疗保险参保者的影响，模型包括了双重参保和事件时间指标的交互项。
本样本包括 2011 年至 2019 年间居住在纽约州的 463947 名患有痴呆症的医疗保险受益人（50.2%年龄小于 85 岁；64.4%为女性）。MLTC 的实施与双重参保者的疗养院使用几率降低相关，从实施后 2 年的 8%的几率降低（调整后的优势比，0.92[95%置信区间，0.86-0.98]）到实施后 6 年的 24%的几率降低（调整后的优势比，0.76[95%置信区间，0.69-0.84]）。与没有 MLTC 的情况相比，MLTC 的实施与 2013 年至 2019 年期间每年 8%的疗养院使用天数减少相关（平均，每年减少 5.6[95%置信区间，5.1-4.1]天）。
这项队列研究的结果表明，纽约州强制性 MLTC 的实施与双重参保者的痴呆症疗养院使用减少相关，MLTC 可能有助于预防或延迟老年痴呆症患者的疗养院安置。
