A Longitudinal Analysis of Site of Death: The Effects of Continuous Enrollment in Medicare Advantage Versus Conventional Medicare

Abstract

This study assessed the odds of dying in hospital associated with enrollment in Medicare Advantage (M-A) versus conventional Medicare Fee-for-Service (M-FFS). Data were derived from the 2008 and 2010 waves of the Health and Retirement Study (n = 1,030). The sample consisted of elderly Medicare beneficiaries who died in 2008–2010 (34% died in hospital, and 66% died at home, in long-term senior care, a hospice facility, or other setting). Logistic regression estimated the odds of dying in hospital for those continuously enrolled in M-A from 2008 until death compared to those continuously enrolled in M-FFS and those switching between the two plans. Results indicate that decedents continuously enrolled in M-A had 43% lower odds of dying in hospital compared to those continuously enrolled in M-FFS. Financial incentives in M-A contracts may reduce the odds of dying in hospital.

Keywords

end-of-life decisions Medicare payment systems incentives in health care health policy hospice good death

Get full access to this article

View all access options for this article.

References

Ache

K. A.

Shannon

R. P.

Heckman

M. G.

Diehl

N. N.

Willis

F. B.

(2011). A preliminary study comparing attitudes toward hospice referral between African American and white American primary care physicians. Journal of palliative medicine, 14, 542–547.

Baily

M. A.

D’Onofrio

Jennings

Ryndes

(2003, 3). Access to hospice care: Expanding boundaries, overcoming barriers. The Hastings Center Report, March–April, Suppl:S3–7.

Bergman

Saigal

C. S.

Lorenz

K. A.

Hanley

Miller

D. C.

Gore

J. L.

Litwin

M. S.

(2011). Hospice use and high-intensity care in men dying of prostate cancer. Archives of Internal Medicine, 171, 204–210.

Borowske

(2012). Straddling the fence: ICU nurses advocating for hospice care. Critical Care Nursing Clinics of North America, 24, 105–116.

Bottrell

M. M.

O’Sullivan

J. F.

Robbins

M. A.

Mitty

E. L.

Mezey

M. D.

(2001). Transferring dying nursing home residents to the hospital: DON perspectives on the nurse’s role in transfer decisions. Geriatric Nursing, 22, 313–317.

Carlson

M. D. A.

Barry

C. L.

Cherlin

E. J.

Mccorkle

Bradley

E. H.

(2012). Hospices’ enrollment policies may contribute to underuse of hospice care in the United States. Health Affairs, 31, 2690–2698.

Carr

(2003). A “Good Death” for whom? Quality of spouse’s death and psychological distress among older widowed persons. Journal of Health and Social Behavior, 44, 215–232.

Centers for Medicare and Medicaid Services. (2014). Fact sheets: CMS finalizes updates to the wage index and payment rates for the Medicare Hospice Benefit for fiscal year 2015. Retrieved January 20, 2015, from http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-08-04-3.html

Connor

S. R.

Pyenson

Fitch

Spence

Iwasaki

(2007). Comparing hospice and nonhospice patient survival among patients who die within a three-year window. Journal of pain and symptom management, 33, 238–246.

10.

Cort

M. A.

(2004). Cultural mistrust and use of hospice care: Challenges and remedies. Journal of Palliative Medicine, 7, 63–71.

11.

Dartmouth Institute for Health Policy and Clinical Practice. (2015). Care of chronic illness in last two years of life. Retrieved January 20, 2015, from http://www.dartmouthatlas.org/data/table.aspx?ind=17&loct=2&loc=2%2c3%2c4%2c5%2c6%2c7%2c8%2c9%2c10%2c11%2c12%2c13%2c14%2c15%2c16%2c17%2c18%2c19%2c20%2c21%2c22%2c23%2c24%2c25%2c26%2c27%2c28%2c29%2c30%2c31%2c32%2c33%2c34%2c35%2c36%2c37%2c38%2c39%2c40%2c41%2c42%2c43%2c44%2c45%2c46%2c47%2c48%2c49%2c50%2c51%2c52

12.

Duggan

Starc

Vabson

(2014). Who benefits when the government pays more? Pass-through in the Medicare advantage program. Working Paper Number 19989. Cambridge, MA: National Bureau of Economic Research.

13.

Emanuel

E. J.

Ash

Gazelle

Levinsky

N. G.

Saynina

… Moskowitz

(2002). Managed care, hospice use, site of death, and medical expenditures in the last year of life. Archives of Internal Medicine, 162, 1722–1728.

14.

Enguidanos

Vesper

Goldstein

(2013). Ethnic differences in hospice enrollment following inpatient palliative care consultation. Journal of Hospital Medicine: An Official Publication of the Society of Hospital Medicine, 8, 598–600.

15.

Evans

W. G.

Cutson

T. M.

Steinhauser

K. E.

Tulsky

J. A.

(2006). Is there no place like home? Caregivers recall reasons for and experience upon transfer from home hospice to inpatient facilities. Journal of palliative medicine, 9, 100–110.

16.

Fairfield

K. M.

Murray

K. M.

Wierman

H. R.

Han

P. K. J.

Hallen

Miesfeldt

… Earle

C. C.

(2012). Disparities in hospice care among older women dying with ovarian cancer. Gynecologic Oncology, 125, 14–18.

17.

Finestone

A. J.

Inderwies

(2008). Death and dying in the US: The barriers to the benefits of palliative and hospice care. Clinical interventions in aging, 3, 595.

18.

Fleischman

R. J.

Mullins

R. J.

McConnell

K. J.

Hedges

J. R.

O. J.

Newgard

C. D.

(2012). Is futile care in the injured elderly an important target for cost savings? The Journal of Trauma and Acute Care Surgery, 73, 146–151.

19.

Ford

D. W.

Nietert

P. J.

Zapka

Zoller

J. S.

Silvestri

G. A.

(2008). Barriers to hospice enrollment among lung cancer patients: A survey of family members and physicians. Palliative and Supportive Care, 6, 357–362.

20.

Goodman

Esty

Fisher

Chang

C. H.

(2011). Trends and variation in end-of-life care for Medicare beneficiaries with severe chronic illness. In Bronner

K. K.

(Ed.), The Dartmouth institute for health policy and clinical practice (pp. 1–44). Dartmouth: The Dartmouth Atlas Project.

21.

Grunier

Mor

Weitzen

Truchil

Teno

Roy

(2007). Where people die: A multilevel approach to understanding influences on site of death in America. Medical Care Research & Review, 64, 351–378.

22.

Idler

E. L.

Benyamini

(1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38, 21–37.

23.

Institute of Medicine. (2014). Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: National Academies Press.

24.

Johnson

K. S.

Kuchibhatla

Tulsky

J. A.

(2011). Racial differences in location before hospice enrollment and association with hospice length of stay. Journal of the American Geriatrics Society, 59, 732–737.

25.

Kelley

A. S.

McGarry

Fahle

Marshall

S. M.

Skinner

J. S.

(2013). Out-of-pocket spending in the last five years of life. Journal of General Internal Medicine, 28, 304–309.

26.

Kollef

M. H.

Ward

(1999). The influence of access to a private attending physician on the withdrawal of life-sustaining therapies in the intensive care unit. Critical Care Medicine, 27, 2125–2132.

27.

Ladd

S. C.

(2014). Systematic review of research literature on African Americans’ end-of-life healthcare preferences. Journal of African American Studies, 18, 373–397.

28.

Levy

C. R.

Ely

E. W.

Payne

Engelberg

R. A.

Patrick

D. L.

Curtis

J. R.

(2005). Quality of dying and death in two medical ICUs: Perceptions of family and clinicians. Chest, 127, 1775–1783.

29.

Maciejewski

M. L.

Dowd

Thiede Call

Feldman

(2001). Comparing mortality and time until death for Medicare HMO and FFS beneficiaries. Health Services Research, 35, 1245–1265.

30.

McCarthy

E. P.

Burns

R. B.

Ngo-Metzger

Davis

R. B.

Phillips

R. S.

(2003). Hospice use among Medicare managed care and fee-for-service patients dying with cancer. JAMA: The Journal of the American Medical Association, 289, 2238–2245.

31.

McWhinney

I. R.

Bass

M. J.

Orr

(1995). Factors associated with location of death (home or hospital) of patients referred to a palliative care team. CMAJ: Canadian Medical Association Journal = Journal De L’Association Medicale Canadienne, 152, 361–367.

32.

Medicare Advantage Plans Cover All Medicare Services. (2016). Retrieved from https://www.medicare.gov/what-medicare-covers/medicare-health-plans/medicare-advantage-plans-cover-all-medicare-services.html

33.

Medicare Payment Advisory Council. (2015). Spending in the last year of life and the impact of hospice on Medicare outlays. Retrieved April 11, 2016, from http://www.medpac.gov/documents/contractor-reports/spending-in-the-last-year-of-life-and-the-impact-of-hospice-on-medicare-outlays-(updated-august-2015).pdf?sfvrsn=0

34.

Morrisey

M. A.

Kilgore

M. L.

Becker

D. J.

Smith

Delzell

(2013). Favorable selection, risk adjustment, and the Medicare advantage program. Health Services Research, 48, 1039–1056.

35.

Newhouse

J. P.

McGuire

T. G.

(2014). How successful is Medicare advantage? Milbank Quarterly, 92, 351–394.

36.

Newhouse

J. P.

Price

Huang

McWilliams

J. M.

Hsu

(2012). Steps to reduce favorable risk selection in Medicare advantage largely succeeded, boding well for health insurance exchanges. Health Affairs (Project Hope), 31, 2618–2628.

37.

Ngo-Metzger

Phillips

R. S.

McCarthy

E. P.

(2008). Ethnic disparities in hospice use among Asian-American and Pacific Islander patients dying with cancer. Journal of the American Geriatrics Society, 56, 139–144.

38.

Niederman

M. S.

Berger

J. T.

(2010). The delivery of futile care is harmful to other patients. Critical Care Medicine, 38, S518–S522.

39.

Obermeyer

Makar

Abujaber

Dominici

Block

Cutler

D. M.

(2014). Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer. JAMA: Journal of the American Medical Association, 312, 1888–1896.

40.

O’Connor

N. R.

Harris

P. S.

Ache

Casarett

D. J.

(2014). Hospice admissions for cancer in the final days of life: Independent predictors and implications for quality measures. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 32, 3184–3189.

41.

Pan

C. X.

Chai

Farber

(2008). Myths of the high medical cost of old age and dying. International Journal of Health Services: Planning, Administration, Evaluation, 38, 253–275.

42.

Phongtankuel

Scherban

B. A.

Reid

M. C.

Finley

Martin

Dennis

Adelman

R. D.

(2016). Why do home hospice patients return to the hospital? A study of hospice provider perspectives. Journal of palliative medicine, 19, 51–56.

43.

Pierson

C. M.

Curtis

J. R.

Patrick

D. L.

(2002). A good death: A qualitative study of patients with advanced AIDS. AIDS Care, 14, 587–598.

44.

Pinkhasov

R. M.

Wong

Kashanian

Lee

Samadi

D. B.

Pinkhasov

M. M.

Shabsigh

(2010). Are men shortchanged on health? Perspective on health care utilization and health risk behavior in men and women in the United States. International Journal of Clinical Practice, 64, 475–487.

45.

Porter

M. E.

(2010). What is value in health care? New England Journal of Medicine, 363, 2477–2481.

46.

Presser

Couper

M. P.

Lessler

J. T.

Martin

Rothgeb

J. M.

Singer

(2004). Methods for testing and evaluating survey questions. Public opinion quarterly, 68, 109–130.

47.

Riley

G. F.

Lubitz

J. D.

(2010). Long-term trends in Medicare payments in the last year of life. Health Services Research, 45, 565–576.

48.

Shugarman

L. R.

Bird

C. E.

Schuster

C. R.

Lynn

(2008). Age and gender differences in Medicare expenditures and service utilization at the end of life for lung cancer decedents. Women’s Health Issues, 18, 199–209.

49.

Silveira

M. J.

Connor

S. R.

Goold

S. D.

McMahon

L. F.

Feudtner

(2011). Community supply of hospice: Does wealth play a role? Journal of Pain and Symptom Management, 42, 76–82.

50.

“Stepwise” StataCorp. 2013. Stata 13 base reference manual. College Station, TX: Stata Press. Retrieved April 11, 2016, from http://www.stata.com/support/faqs/resources/citing-software-documentation-faqs/

51.

Stevenson

D. G.

Ayanian

J. Z.

Zaslavsky

A. M.

Newhouse

J. P.

Landon

B. E.

(2013). Service use at the end-of-life in Medicare advantage versus traditional Medicare. Medical Care, 51, 931–937.

52.

Teno

J. M.

Gruneir

Schwartz

Nanda

Wetle

(2007). Association between advance directives and quality of end-of-life care: A national study. Journal of the American Geriatrics Society, 55, 189–194.

53.

Teno

J. M.

Lynn

Connors

A. F.

Jr Wenger

Phillips

R. S.

Alzola

… Knaus

W. A.

(1997). The illusion of end-of-life resource savings with advance directives. SUPPORT investigators. Study to understand prognoses and preferences for outcomes and risks of treatment. Journal of the American Geriatrics Society, 45, 513–518.

54.

Teno

J. M.

Shu

J. E.

Casarett

Spence

Rhodes

Connor

(2007). Timing of referral to hospice and quality of care: Length of stay and bereaved family members’ perceptions of the timing of hospice referral. Journal of Pain & Symptom Management, 34, 120–125.

55.

The Henry J. Kaiser Family Foundation. (2013a). Medicaid managed care enrollees. Retrieved January 20, 2015, from http://kff.org/medicaid/state-indicator/total-medicaid-mc-enrollment/

56.

The Henry J. Kaiser Family Foundation. (2013b). Medicare advantage fact sheet. Retrieved January 20, 2015, from http://kff.org/medicare/fact-sheet/medicare-advantage-fact-sheet

57.

The Henry J. Kaiser Family Foundation. (2014). Medicare advantage enrollees as a percent of total Medicare population. Retrieved January 20, 2015, from http://kff.org/medicare/state-indicator/enrollees-as-a-of-total-medicare-population/

58.

The Medicare Payment Advisory Commission. (2013). Report to congress (March 2013) - Section 12: Hospice services. Washington, DC: Medicare Payment Advisory Commission.

59.

Tonelli

M. R.

(1996). Pulling the plug on living wills: A critical analysis of advance directives. CHEST Journal, 110, 816–822.

60.

Washington

K. T.

Bickel-Swenson

Stephens

(2008). Barriers to hospice use among African Americans: A systematic review. Health & social work, 33, 267–274.

61.

Wenger

N. S.

Rosenfeld

(2001). Quality indicators for end-of-life care in vulnerable elders. Annals of Internal Medicine, 135, 677.

62.

Wright

A. A.

Keating

N. L.

Balboni

T. A.

Matulonis

U. A.

Block

S. D.

Prigerson

H. G.

(2010). Place of death: Correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 28, 4457–4464.

63.

Wright

A. A.

Zhang

Ray

Mack

J. W.

Trice

Balboni

… Prigerson

H. G.

(2008). Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA: The Journal of the American Medical Association, 300, 1665–1673.

64.

Zhang

Wright

A. A.

Huskamp

H. A.

Nilsson

M. E.

Maciejewski

M. L.

Earle

C. C.

… Prigerson

H. G.

(2009). Health care costs in the last week of life: Associations with end-of-life conversations. Archives of Internal Medicine, 169, 480.