Quality of End-of-Life Care for Medicare Advantage Enrollees—Does It Measure Up? | Geriatrics | JAMA Network Open | JAMA Network
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Invited Commentary
October 13, 2020

Quality of End-of-Life Care for Medicare Advantage Enrollees—Does It Measure Up?

Author Affiliations
  • 1Department of Health Services, Policy and Practice, Brown University School of Public Health
JAMA Netw Open. 2020;3(10):e2021063. doi:10.1001/jamanetworkopen.2020.21063

In many cases, the end-of-life period is marked by a long series of burdensome health care transitions. In 2015, nearly 29% of decedents who were enrolled in the traditional Medicare program received intensive care during the last 30 days of life—an increase from 24% in 2000—and 11% experienced these health care transitions in the last 3 days of life.1 Previous research using interviews of bereaved family members and friends of decedents found that health care transitions in the last 3 days of life were associated with more unmet needs, higher rates of concern, and lower ratings of quality of care than when such transitions were absent, especially when the transition was between a nursing home and a hospital.2 Proper handling of these transitions at the end of life involves careful care management. 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. 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.3 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.4 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 al5 provides the first evidence to date that Medicare Advantage plans may have some room for improvement.

Ankuda et al5 found that, compared with decedents who were enrolled in traditional Medicare plans, the loved ones of decedents enrolled in Medicare Advantage plans were more likely to report that care was not excellent, and that they were not kept well informed in the last month of the decedent’s life. 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. Sicker Medicare Advantage enrollees appeared to disenroll from the program at much higher rates than those of healthy enrollees.6 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.

What might be the reason for these poor experiences? Ankuda et al5 suggest that it could be owing to narrow the network designs that many Medicare Advantage plans have, which may restrict enrollees from getting care from their preferred health care facilities and limit care to lower-quality facilities.7 These facilities may be understaffed and may not be able to provide the necessary attention to patients with the greatest needs. Another possibility could be that Medicare Advantage plans may enforce a detailed care protocol that might not be flexible enough to incorporate a patient’s needs. For instance, if an enrollee’s religious beliefs preclude the use of a specific treatment modality at the end of life, a plan may not agree to cover the treatment without a lengthy process of prior authorization. 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. 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,7 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.

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Article Information

Published: October 13, 2020. doi:10.1001/jamanetworkopen.2020.21063

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Rahman M et al. JAMA Network Open.

Corresponding Author: Momotazur Rahman, PhD, 121 South Main Street, S-6, Providence, RI 02912 (momotazur_rahman@brown.edu).

Conflict of Interest Disclosures: Drs Rahman and Gozalo reported grants from National Institutes of Health-National Institute on Aging during the conduct of the study. No other disclosures were reported.

Teno  JM, Gozalo  P, Trivedi  AN,  et al.  Site of death, place of care, and health care transitions among US Medicare beneficiaries, 2000-2015.   JAMA. 2018;320(3):264-271. doi:10.1001/jama.2018.8981PubMedGoogle ScholarCrossref
Makaroun  LK, Teno  JM, Freedman  VA, Kasper  JD, Gozalo  P, Mor  V.  Late transitions and bereaved family member perceptions of quality of end-of-life care.   J Am Geriatr Soc. 2018;66(9):1730-1736. doi:10.1111/jgs.15455PubMedGoogle ScholarCrossref
Teno  JM, Clarridge  BR, Casey  V,  et al.  Family perspectives on end-of-life care at the last place of care.   JAMA. 2004;291(1):88-93. doi:10.1001/jama.291.1.88PubMedGoogle ScholarCrossref
Meyers  DJ, Durfey  SNM, Gadbois  EA, Thomas  KS.  Early adoption of new supplemental benefits by Medicare Advantage plans.   JAMA. 2019;321(22):2238-2240. doi:10.1001/jama.2019.4709PubMedGoogle ScholarCrossref
Ankuda  CK, Kelley  AS, Morrison  RS, Freedman  VA, Teno  JM.  Family and friend perceptions of quality of end-of-life care in Medicare Advantage vs traditional Medicare.   JAMA Netw Open. 2020;3(10):e2020345. doi:10.1001/jamanetworkopen.2020.20345Google Scholar
Meyers  DJ, Belanger  E, Joyce  N, McHugh  J, Rahman  M, Mor  V.  Analysis of drivers of disenrollment and plan switching among Medicare Advantage beneficiaries.   JAMA Intern Med. 2019;179(4):524-532. doi:10.1001/jamainternmed.2018.7639PubMedGoogle ScholarCrossref
Meyers  DJ, Mor  V, Rahman  M.  Medicare Advantage enrollees more likely to enter lower-quality nursing homes compared to fee-for-service enrollees.   Health Aff (Millwood). 2018;37(1):78-85. doi:10.1377/hlthaff.2017.0714PubMedGoogle ScholarCrossref
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