Does Managed Care Improve End-of-Life Care for Medicare Beneficiaries?

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PROJECT SUMMARY Numerous studies and a recent Institute of Medicine report have raised concerns about the quality of end-of- life (EOL) care provided to older adults in the United States. Many Medicare beneficiaries receive burdensome treatments (e.g. feeding tube placement, dialysis, and intensive care unit stays) that do not extend their life, die in a hospital, and experience transitions from one setting of care to another late in life. These treatments come at significant financial and emotional cost to the Medicare program, individual beneficiaries and their families, and are associated with the financial incentives and fragmented delivery system embedded in Fee-for-Service (FFS) Medicare. Despite repeated calls to improve patient experiences at the end-of-life (EOL), especially for older adults with Alzheimer's Disease and Related Dementias (ADRD) and other life-limiting illness, little research has considered whether managed care could achieve these goals. Medicare Advantage (MA), the voluntary, managed care alternative to FFS now covers 33% of Medicare beneficiaries at time of death. MA plans receive capitated payments for each beneficiary and are shielded from the cost of most care provided to beneficiaries who enroll in hospice care. These incentives may encourage provision of high-quality EOL care for terminally ill patients. While a small number of descriptive studies point to more appropriate EOL care provision with managed care, the literature has not yet accounted for non-random enrollment in MA, studied MA across market conditions, assessed EOL care for patients with life-limiting illness in MA or examined outpatient EOL care in MA. To address this gap, our team of health economists, health services researchers, physicians and nurse practitioners will use econometric methods with Medicare claims data from 2015 – 2018 including newly available Medicare Advantage encounter data to assess whether and how managed care enrollment affects care for patients with life-limiting illnesses (ADRD, metastatic cancer and end-stage organ failure). We will 1- test whether MA reduces use of potentially inappropriate care near the end-of-life for these patients; 2- assess whether MA provides better outpatient care near the end-of-life to reduce potentially burdensome transitions; and 3- test whether the effect of MA varies with local practice styles, plan payments, and MA market share. The end-of-life represents the most intensive period of healthcare utilization for many Americans. With one- third of Medicare beneficiaries now receiving coverage through MA, it is critical to understand potential differences in the quality of care provided at this time. Information about differences between managed care and traditional Medicare is essential to understand how financial incentives influence EOL care and to develop incentives that better align with patient preferences.