Does Medicare Properly Cover End-of-Life Care for All Beneficiaries?

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A number of studies have raised concerns with the quality of end-of-life (EOL) care provided to seniors in the United States, noting relatively few changes over the past three decades. It is suggested that this is a result of differences in coverage between Medicare Advantage (MA) and traditional Medicare (TM), with some patients having a better experience than others.

In a study published by JAMA Health Forum, researchers compared EOL care between 360,430 MA beneficiaries and 659,135 TM beneficiaries between 2016 and 2018. The study implemented a retrospective analysis of Medicare claims data among older Medicare beneficiaries who died in that timespan, all with one or more emergent hospitalizations with a life-limiting condition that would likely qualify for hospice care.

Results suggested that there are considerable differences in the types of care received near the end of life, with MA enrollees being less likely to receive potentially burdensome treatments and a lower likelihood of dying in a hospital by 3.3%. Despite, these statistics, MA enrollees were 1.3% more likely to die in the hospital if admitted compared to TM beneficiaries.

Further, MA enrollees were 5.2% less likely to be transferred to rehabilitative or skilled nursing facilities post-discharge, with most cases involving discharges to home care. Lastly, MA enrollees were slightly more likely to use hospice care earlier than TM beneficiaries, with 16% receiving hospice care for 30 days before death compared to 15% for TM beneficiaries.¹

“For patients near the end-of-life, [Medicare Advantage] incentives may reduce potentially burdensome care and encourage hospice but could also restrict access to costly but necessary services,” said Lauren Hersch Nicholas, PhD, MPP, health economist, University of Colorado Department of Medicine, study lead, according to the University of Colorado Anschutz Medical Campus, in a press release. “Medicare Advantage was associated with generally less aggressive health care utilization near the end of life—fewer hospitalizations and less invasive medical care if you are hospitalized, lower rates of things like feeding tubes and dialysis and mechanical ventilations. But there were also some concerning patterns. Once a patient was hospitalized, those in Medicare Advantage were more likely to die in the hospital than elsewhere, which could mean that the hospitalization came after care was delayed and nothing else could be done.”²

The researchers suggested that the results mirrored concerns raised by the Office of the Inspector General about coverage denials for skilled nursing and other important services in MA. Further, the researchers suggested that these patients could benefit from the care coordination and home-based services that MA plans have the flexibility to offer, but the outcomes did not meaningfully differ relative to all decedents. It is also believed that family caregiving or out-of-pocket spending may have been required to fill this gap.¹

“This cross-sectional analysis of health care utilization in the last 6 months of life found that MA enrollment was associated with lower levels of facility-based care, including potentially burdensome treatments and admissions, and slightly higher rates of hospice use,” explained the study authors. “Additional home care partially offset lower rates of skilled nursing for those with hospitalizations in the last year of life. Thus, our findings suggest that MA plans have the potential to reduce burdensome treatments for patients approaching the EOL, although it is not possible to establish if these findings align with patients’ preferences or provide appropriate care. In addition, the higher rates of discharge home after hospitalization may shift care burdens to informal caregivers if Medicare beneficiaries enrolled in MA plans lack adequate formal support services after a hospitalization.”

References

1. Medicare-Covered Services Near the End of Life in Medicare Advantage vs Traditional Medicare. JAMA Network. July 19, 2024. Accessed July 22, 2024. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2821204

2. How well does Medicare cover end-of-life care? It depends on what type. EurekAlert! July 19, 2024. Accessed July 22, 2024. https://www.eurekalert.org/news-releases/1051977