Family and Friend Perceptions of Quality of End-of-Life Care in Medicare Advantage vs Traditional Medicare

“Our study of the quality of end-of-life care in MA [Medicare Advantage] plans comes as the Centers for Medicare & Medicaid Services is set to start testing a “carve-in” of hospice services in 2021, meaning that hospice will be a covered benefit within MA and therefore MA plans will take a more active role in hospice services. Currently, the hospice benefit is “carved out” from MA, although MA plans are still involved in the care of hospice enrollees through several mechanisms. Older adults in MA are more likely to receive hospice services, potentially through direct care coordination or by contracting with clinicians or facilities more likely than MA to refer to hospice. The MA plan is permitted to guide beneficiaries to specific hospices and oversee aspects of their care, but it is not permitted to restrict access to a defined hospice network. When an MA beneficiary elects hospice, traditional Medicare will then cover most benefits, including hospice, but the MA plan will still cover drugs and treatments for conditions unrelated to the hospice terminal diagnosis, as well as any supplementary benefits and cost sharing that are part of the MA plan.

[..] We identified 2119 individuals in NHATS [National Health and Aging Trends Study] who died while enrolled in Medicare between 2011 and 2017, with 670 of those individuals (weighted proportion, 32.7%) enrolled in MA at the time of death or before hospice enrollment. [..] This population was poorer than the overall Medicare population, with 40.3% (95% CI, 37.1% to 43.5%) in the lowest income quartile for all Medicare beneficiaries. Of 2119 patients, 83.9% (95% CI, 81.7% to 85.9%) had impaired activities of daily living in the last NHATS survey conducted before death and 1.0% (95% CI, 38.6% to 43.4%) were bedbound in the last month of life.

[..] As demonstrated in the propensity score–weighted model, the bereaved family or friends of those who died while in MA were more likely to report that the overall quality of care was not excellent (adjusted odds ratio, 1.28; 95% CI, 1.01 to 1.61). This translates to an estimated probability of 53.1% (95% CI, 50.0% to 56.3%) of respondents reporting that care was not excellent for individuals with traditional Medicare, compared with 59.0% (95% CI, 54.4% to 63.5%) for those with MA.

[..] Stratified by care settings (ie, died at home vs not at home, hospital care at end of life vs no hospital care at end of life, and nursing home care at end of life vs no nursing home care at end of life), there is a significant gap between MA and traditional Medicare for those who received care in the nursing home at the end of life: there was an estimated probability of 57.2% that family or friend respondents of individuals with traditional Medicare would report that care was not excellent, compared with 77.9% for family or friend respondents of those with MA (marginal increase for those in MA, 0.21; 95% CI, 0.08 to 0.32).

[..] Prior studies have demonstrated the strong influence MA plans have on postacute and institutional care, such as skilled nursing, home health, and nursing home care. MA plans may be restricting their networks to facilities and agencies that are willing to accept lower prices and that consequently may cut staff or other expenses important to the perceived quality of care of these older adults, who are at increased risk. This hypothesis is supported by evidence that MA plans refer to skilled nursing facilities and home health agencies with lower ratings for quality. It is additionally supported by our finding of a significant gap in perceived quality between MA and traditional Medicare for individuals residing in nursing homes at the end of life. While we did find that perceived quality of care was greater for individuals enrolled in hospice, MA enrollees in hospice still experienced lower perceived quality of care than traditional Medicare enrollees in hospice.”

Full article, Ankuda CK, Kelley AS, Morrison RS et al. JAMA Network Open, 2020.10.13

“In the Medicare Advantage program, plans are paid on a capitated basis to cover the needs of enrollees each year. This gives plans a strong incentive to manage the care of enrollees, particularly in terms of reducing avoidable burdensome health care transitions. Medicare Advantage plans may be in a position to provide care management services that are not available to beneficiaries enrolled in traditional Medicare plans, allowing patients to transition from nursing homes to home settings, where family members of descendants tend to report better end-of-life experiences. Medicare Advantage plans can implement incentives to improve advanced care planning, which can play an important role in improving end-of-life care. These plans also have been granted flexibility to cover a range of home-based palliative care services. Hospice care, which has been associated with improved end-of-life quality of care, has been carved out of the Medicare Advantage benefits, incentivizing the referral of potentially costly beneficiaries to hospice by Medicare Advantage plans. Despite these opportunities, the current study from Ankuda et al provides the first evidence to date that Medicare Advantage plans may have some room for improvement.

[..] Sicker Medicare Advantage enrollees appeared to disenroll from the program at much higher rates than those of healthy enrollees. However, such disenrollment complicates the comparison of end-of-life outcomes between traditional Medicare and Medicare Advantage enrollees, and it is unclear how disenrollment may impact the perceived quality of care.

[..] No matter what the reasons, ensuring access to high-quality care at the end of life is of the utmost importance given the impending implementation of the Medicare Advantage carve-in model of hospice service coverage starting in 2021. This model may lead to a larger share of enrollees in the Medicare Advantage program and will require detailed monitoring to ensure that quality standards for end-of-life care are met by plans. Whether Medicare Advantage enrollees will have adequate access to high-quality hospice care in this new model will also necessitate scrutiny. Given that previous research has found that Medicare Advantage enrollees tend to be admitted to lower-quality hospitals and nursing homes, it will be critical to ensure that they are not preferentially referred to lower-quality hospice facilities that may save money for the plan at the cost of providing fewer visits and lower-quality end-of-life care.

Medicare Advantage plans are in a unique position to offer high-value end-of-life benefits to enrollees that are unavailable in traditional Medicare plans, and the care management that these plans offer may reduce burdensome health care transitions. As Medicare Advantage plans enter this next frontier in care management, careful monitoring measures are warranted to ensure that this potential advantage is met.”

[Editorial] Quality of End-of-Life Care for Medicare Advantage Enrollees—Does It Measure Up?, Rahman M, Meyers DJ and Gozalo P. JAMA Network Open, 2020.10.13