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

项目摘要 许多研究和最近的一份医学研究所报告引起了人们对终止妊娠质量的担忧。 美国为老年人提供的终身护理。许多医疗保险受益人收到负担沉重的 不能延长寿命的治疗（如放置饲管、透析和重症监护病房）死亡 在医院，并经历从一种护理环境到另一种护理环境的过渡。这些治疗方法 对医疗保险计划、个人受益人及其家庭来说， 并与嵌入在收费服务中的财务激励和分散的交付系统有关 (FFS)医疗保险尽管一再呼吁改善患者在生命末期（EOL）的体验，特别是对于 患有阿尔茨海默病和相关痴呆症（ADRD）和其他限制生命的疾病的老年人， 研究已经考虑了管理式护理是否能够实现这些目标。 Medicare Advantage（MA）是FFS的自愿管理式护理替代方案，现在覆盖了33%的Medicare 死亡时的受益人。MA计划为每个受益人接收资本付款，并被屏蔽 从为参加临终关怀的受益人提供的大多数护理费用中扣除。这些激励措施可能 鼓励为绝症患者提供高质量的终末期护理。虽然有少数描述性的 研究指出，管理式护理更适合提供EOL护理，但文献尚未说明 对于MA的非随机入组，研究了不同市场条件下的MA，评估了患者的EOL治疗， 在MA中患有限制生命的疾病或在MA中接受门诊EOL治疗。 为了解决这一差距，我们的健康经济学家，卫生服务研究人员，医生和护士团队 从业者将使用计量经济学方法与医疗保险索赔数据从2015年至2018年，包括新的 可用的Medicare Advantage遭遇数据，以评估管理式医疗登记是否以及如何影响 为患有限制生命的疾病（ADRD、转移性癌症和终末期器官衰竭）的患者提供护理。我们将1- 测试MA是否减少了这些患者在生命末期使用潜在的不适当护理; 2-评估 MA是否在临终前提供更好的门诊护理，以减少潜在的过渡负担; 检验并购的效果是否随当地的实践风格、计划支付和并购市场份额而变化。 对于许多美国人来说，生命的尽头是医疗保健利用最密集的时期。其中一个- 目前，三分之一的医疗保险受益人通过MA获得保险，了解潜在的风险是至关重要的。 在这一时期提供的护理质量的差异。关于管理式护理之间差异的信息 传统的医疗保险对于了解经济激励如何影响EOL护理和发展 更好地与患者偏好保持一致的激励措施。

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.