Not all versions of Medicare are created equal – and when it comes to end-of-life care, some versions may serve a patient's needs better than others. That's the focus of newly published research by Lauren Hersch Nicholas, PhD, MPP, a University of Colorado Department of Medicine and CU Cancer Center health economist, and her colleagues.
The researchers analyzed the experiences of more than a million people receiving Medicare-funded services in the last six months of their lives. Many of these patients had one or more life-limiting illnesses at the time of death, including cancer, dementia, and end-stage organ failure.
Their paper was published July 19 in JAMA Health Forum.
What Nicholas and her colleagues found is that the kind of Medicare a patient is enrolled in can make a difference in whether that patient gets certain treatments, and whether the patient dies in a hospital or in hospice care.
No one right answer
Nicholas and her colleagues examined two broad types of Medicare: Traditional Medicare, the hospital and medical insurance programs (Parts A and B) provided by the government; and Medicare Advantage Plans, the alternative coverage provided by Medicare-approved private companies.
"Medicare Advantage is a managed care option that includes additional benefits along with limited provider networks," Nicholas says. "Traditional Medicare offers more flexibility in which doctors patients can see but less financial protection."
As to which version of Medicare is best for end-of-life patients, the results suggest there is no one right answer for everyone because the needs and wishes of patients and their families differ.
"None of us want to think about getting sicker," says Nicholas, a professor in the Division of Geriatric Medicine who's also on the faculty of the CU Center for Bioethics and Humanities. "But the Medicare plan that you choose when you're relatively healthy may have implications for what care you're able to access down the line."
'Potentially burdensome'
Nicholas says her new study "united two of my long-term research interests. I've been working on differences in Medicare since my dissertation research, which was focused mostly on quality of care and potentially preventable hospitalizations. And I've also done a lot of work on end-of-life care, where we have a lot of quality challenges, and where we spend a ton of money on care that patients and their families later are often not happy about, so it's an area with great potential for improvement."
The researchers analyzed claims records covering the last six months of life of 360,430 people nationwide enrolled in Medicare Advantage and 659,135 traditional Medicare enrollees who died between 2016 and 2018. About half of those in both groups had various life-limiting illnesses.
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For some of these patients, certain invasive treatments – including mechanical ventilation, feeding or breathing tubes, intravenous feeding, or dialysis – could be what the study terms "potentially burdensome," meaning they "are costly and do not significantly extend length of life or improve quality of life." For other patients, such treatments might be classified as "appropriate."
Likewise, the study says, frequent hospitalizations in the last few months of life may be of less benefit to some patients than others. "Despite preferences for home, patients often die in hospitals and nursing homes, experiencing transitions from one health care setting of care to another late in life," the study says.
Concerning patterns
The study notes that Medicare Advantage is a managed-care alternative to traditional Medicare's fee-for-service model. Companies that provide Medicare Advantage plans get fixed monthly payments per enrollee regardless of actual service use. As such, Medicare Advantage is designed to reduce over-utilization of medical services.
"For patients near the end-of-life, [Medicare Advantage] incentives may reduce potentially burdensome care and encourage hospice," Nicholas' paper says, "but could also restrict access to costly but necessary services."
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Nicholas says her research found that "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," she adds. "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."
Nicholas says that Medicare Advantage "does have a number of features and incentives that could improve the quality of care for some end-of-life patients, but you might also worry about these plans denying some treatments and leaving very sick, vulnerable people with unmet needs."
Hospitalization and hospice
Among the study's key findings:
- Medicare Advantage patients in the study were less likely to receive potentially burdensome treatments in the last six months of life than patients enrolled in traditional Medicare.
- If hospitalized in the last six months of life, the Medicare Advantage patients were more likely to die in the hospital than were traditional-Medicare enrollees, who were more likely to die elsewhere, including in hospice care.
- If hospitalized in the last six months of life and then discharged, Medicare Advantage patients were less likely to receive care at skilled nursing facilities than traditional-Medicare patients, and more likely to receive their end-of-life care at home.
- "Receipt of less facility-based and potentially burdensome care near the end-of-life may improve quality of care" for Medicare Advantage patients, the study concludes. "However, the greater reliance on home-based care may leave patients with unmet needs or relying on informal care assistance" from family members or others.
Having a conversation
"Our research points to the need to have a family conversation about the end of life, and what family members do or don't want to do to help with that," Nicholas says.
Nicholas notes that her study did not distinguish between traditional-Medicare patients who also had a supplemental private insurance plan (often known as Medigap) to pay extra costs, and those without a Medigap plan. The study also did not differentiate among the various Medicare Advantage Plans, which often charge different out-of-pocket costs and have different rules for service.
Co-authors of the study include CU Department of Medicine faculty members Stacy Fischer, MD, and Christine Jones, MD, as well as Marcelo Perraillon, PhD, of the Colorado School of Public Health. Fischer and Perraillon are also CU Cancer Center members. Alicia Arbaje, MD, PhD, and Daniel Polsky, PhD, both at Johns Hopkins University, also co-authored.
