Medicare Advantage and End of Life Care for Patients with Advanced Dementia

尽管越来越多的美国人死于痴呆症， 在生命的最后阶段接受不理想的护理。报告的问题包括诊断不足和穷人 治疗疼痛，痛苦和不必要的调查和不适当的使用侵略性 治疗。一些研究报告说，资本医疗保险优势（MA）计划， 按个人（而不是按服务）付费，可能比 传统的按服务收费的医疗保险，以促进年底推荐服务的使用， 同时阻止不必要的住院和侵入性手术。此外该 临终关怀的“剥离”也为MA计划促进临终关怀创造了强大的财政激励 在他们的绝症病人中登记。另一方面，资本化支付激励 MA计划有选择地与医疗服务提供者签订合同，并限制服务和选择 供应商为了控制成本。千年评估受益人如果接受护理，将面临更高的费用分摊 来自其网络之外的供应商。狭窄的网络也会影响护理质量 如果高质量的供应商不愿意接受低支付率，则直接支付。因此 服务使用和护理质量的MA注册之间的关系可能是以下因素的混合 不同结果和患者之间的不同影响，需要强有力的经验证据 影响的方向和程度。这一领域的许多现有文献 重点关注少数卫生服务的使用，没有考虑MA中潜在的选择偏倚 在2010年卫生改革伴随的入学变化之前， 专门针对痴呆症患者。我们的研究采用了多波独特的人口- 基于与健康和退休研究（HRS）相关的死亡率随访数据（2000- 2014）和国家健康和老龄化趋势研究（NHATS）（2012-2017），以检查 MA注册与三类临终关怀结局之间的关系：模式 护理（包括死亡部位）、自付支出和生命终末期的感知质量 在老年痴呆症患者中。它还利用核心HRS和NHATS文件来说明 痴呆症死亡者保险覆盖的纵向模式。我们亦建议 一些敏感性和异质性分析，以提高我们的研究结果的鲁棒性。

Even though a growing number of Americans are dying with dementia, several receive suboptimal care near the end of life. Reported problems include under-diagnosis and poor treatment of pain, painful and unnecessary investigations and inappropriate use of aggressive treatments. Some studies have reported that capitated Medicare-Advantage (MA) plans, that are paid on a per-person (rather than a per-service) basis, may be better positioned than traditional fee-for-service Medicare to promote the use of recommended services at the end of life while discouraging unnecessary hospitalizations and invasive procedures. In addition, the hospice “carve-out” also creates a strong financial incentive for MA plans to promote hospice enrollment among their terminally ill patients. On the other hand, capitated payments incentivize MA plans to selectively contract with health providers and restrict services and choice of providers in order to control costs. MA beneficiaries face higher cost-sharing if they receive care from providers outside of their network. Narrow networks can also influence quality of care directly if higher-quality providers are unwilling to accept low payment rates. Therefore, the relationship between MA enrollment on service use and quality of care is potentially a mixture of different effects that vary across outcomes and patients, necessitating robust empirical evidence on both the direction and magnitude of these effects. Much of existing literature in this area focuses on the use of a few health services, does not account for potential selection bias in MA enrollment, precedes enrollment changes accompanying the 2010 health reform, and does not specifically focus on dementia patients. Our study employs multiple waves of unique population- based mortality follow-back data associated with the Health and Retirement Study (HRS) (2000- 2014) and the National Health and Aging Trends Study (NHATS) (2012-2017) to examine the relationship between MA enrollment and three categories of end of life care outcomes: patterns of care (including site of death), out-of-pocket expenditures and perceived quality of end of life care, among dementia decedents. It also harnesses the core HRS and NHATS files to account for longitudinal patterns of insurance coverage among dementia decedents. We also propose several sensitivity and heterogeneity analyses to enhance the robustness of our findings.