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，但仍有一些人接受了 接近生命末期的次佳护理。报告的问题包括诊断不足和较差 治疗疼痛、痛苦和不必要的调查以及不适当地使用攻击性药物 治疗。一些研究报告称，首肯的联邦医疗保险优势(MA)计划， 按人(而不是按服务)付费，可能比 传统的按服务收费的医疗保险在年末推广使用推荐服务 在不鼓励不必要的住院治疗和侵入性手术的同时，保护生命。此外， 临终关怀“创业”也为促进临终关怀的MA计划创造了强大的财务激励 在他们的绝症患者中登记。另一方面，首肯的付款激励了 马云计划有选择地与医疗服务提供者签约，并限制服务和选择 供应商，以控制成本。如果MA受益人接受护理，他们将面临更高的费用分担 来自其网络之外的提供商。狭窄的网络也会影响护理质量 如果较高质量的供应商不愿接受较低的付款率，直接使用。因此， 服务使用方面的MA注册与护理质量之间的关系可能是混合的 不同结果和不同患者的不同影响，需要强有力的经验证据 这些影响的方向和大小。这一领域的许多现有文献 侧重于少数健康服务的使用，不考虑MA中潜在的选择偏见 注册，先于2010年医疗改革的注册更改，而不是 特别关注痴呆症患者。我们的研究使用了多波独特的种群- 基于与健康和退休研究(HRS)相关的死亡率跟踪数据(2000- 2014)和国家健康与老龄化趋势研究(NHATS)(2012-2017)，以审查 MA注册与三类临终关怀结局的关系：模式 护理(包括死亡地点)、自付费用和生命末期的感知质量 护理，在痴呆症患者中。它还利用核心HRS和NHATS文件来说明 关于痴呆症患者的保险覆盖的纵向模式。我们还提议 几个敏感性和异质性分析，以增强我们的发现的稳健性。

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.