Accountability needed with Medicare Advantage’s rapid growth

Family and friends of people who died while enrolled in Medicare Advantage reported lower quality of care in the last month of life compared with those who died while enrolled in traditional Medicare, a cross-sectional study found.

Adjusted propensity score-weighted analysis showed family and friends of decedents in Medicare Advantage were more likely to report that care was not excellent (OR 1.28, 95% CI 1.01-1.61; P=0.04) and that they were not being kept informed (OR 1.48, 95% CI 1.06-2.05; P=0.02) compared with those in Medicare, reported Claire Ankuda, MD, MPH, of the Icahn School of Medicine at Mount Sinai in New York City.

“These findings suggest that, given the rapid growth of Medicare Advantage, Medicare should take steps to ensure that Medicare Advantage plans are held accountable for quality of care at the end of life,” they wrote in JAMA Network Open.

“This dissatisfaction can be reflected in enrollment as well; between January 2017 and December 2017, the Medicare Advantage disenrollment rate was approximately 2% among all beneficiaries, but was 4% among those who had died,” noted Momotazur Rahman, PhD, of Brown University, and co-authors in an accompanying editorial. “Sicker Medicare Advantage enrollees appeared to disenroll from the program at much higher rates than those of healthy enrollees.”

Some Medicare Advantage plan restrictions that keep enrollees from their preferred health care facilities or limit care to lower-quality facilities, they noted. In addition, “Medicare Advantage plans may enforce a detailed care protocol that might not be flexible enough to incorporate a patient’s needs,” they wrote. “In general, prior authorization requirements may induce additional stress and delays in access to health care services at the end of life.”

“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,” they added. “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.”

End-of-life care often involves health care transitions: 11% of traditional Medicare enrollees received intensive care during the last 3 days of life in 2015, and 29% in the last 30 days. A 2018 study of Medicare enrollees found that of those with late transitions, bereaved respondents were more likely to report decedents were treated without respect, had more unmet needs for spiritual support, and were not kept informed about the person’s condition.

“Proper handling of these transitions at the end of life involves careful care management,” the editorialists wrote. “Some would argue that the Medicare Advantage program would be better suited to this role than traditional Medicare.”

“In the Medicare Advantage program, plans are paid on a capitated basis to cover the needs of enrollees each year,” they added. “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 provide care management services not available in traditional Medicare, allowing patients to move from nursing home to a home where end-of-life experiences are often reported as better, they noted. They also may implement incentives to improve advanced care planning and have the flexibility to cover a range of home-based palliative care services. Hospice care, associated with improved end-of-life quality of care, has been carved out of Medicare Advantage benefits until 2021, incentivizing the referral of potentially costly beneficiaries to hospice, they added.

However, a 2018 study found that Medicare Advantage enrollees tend to be admitted to lower-quality hospitals and nursing homes.

In this study, Ankuda and colleagues used data from the National Health and Aging Trends Study, an annual survey of a national U.S. cohort of adults 65 or older that interviews proxies about decedents’ last month of life. Proxies who were not friends or family were excluded. Linked Medicare files determined insurance status in the last month of life.

Of 2,119 included decedents between 2011 and 2017, about 54% were women and 43% older than 85 at death. A third (32.7%) were enrolled in Medicare Advantage at the time of death or prior to hospice (32.7%) and two-thirds (67.3%) in traditional Medicare.

Quality of care was assessed by interview considering pain and symptom management, communication, decision-making, and emotional support, with an overall quality rating (excellent, very good, good, fair, or poor). Low-quality care was defined as any of the following: did not receive the right amount of help for symptoms; not always treated with respect; decisions made that the decedent would not have wanted or without patient or family input; and family members not always kept informed about patient condition.

For nursing home residents, non-excellent care was reported for 77.9% of respondents for individuals with Medicare Advantage compared to 57.2% with traditional Medicare (marginal increase 0.21, 95% CI 0.08-0.32; P=0.001).

Limitations include those inherent to cross-sectional, observational studies, including inability to determine causality. Types of Medicare Advantage plans (e.g., special needs vs health maintenance organization or preferred provider organization) were not compared. Also, only family and close friends familiar with decedent end-of-life care were included, which may bias findings.

  1. Family and friends of patients who died while enrolled in Medicare Advantage reported lower quality of care in the last month of life compared with those who died while enrolled in traditional Medicare, a cross-sectional study found.

  2. With the rapid growth of Medicare Advantage, the findings suggest Medicare should take steps to ensure that Medicare Advantage plans are held accountable for end-of-life quality of care, the researchers said.

Paul Smyth, MD, Contributing Writer, BreakingMED™

Ankuda was funded by a grant from the National Palliative Care Research Center.

Rahman reported grants from the National Institute on Aging.

Cat ID: 494

Topic ID: 398,494,282,494,791,192,255,462,463,60,925