Approximately 25% of all Medicare expenditures are for care received in the last year of life.1 Much research has been done to understand cost and utilization patterns for Medicare beneficiaries at the end of life (EOL).2 However, when assessing EOL costs, most studies focus on decedents with traditional fee-for-service (FFS) Medicare owing to the lack of cost and utilization data for the 30% of Medicare beneficiaries in Medicare Advantage (MA) plans.3 This gap is a cause for concern because utilization and quality of care may differ between MA and FFS beneficiaries.4- 6 We sought to examine differences in characteristics of decedents in MA and FFS Medicare based on detailed survey data.
The Health and Retirement Study (HRS) is a biennial longitudinal survey of a nationally representative cohort of US adults 51 years or older that measures a broad range of questions about health and aging. Between interview cycles, the HRS identifies participants who have died using information from family members and the National Death Index. We included decedents 65 years or older who died between the 1998 and 2012 survey waves and who authorized their HRS responses to be linked to Medicare data. We compared demographic, health, and functional and cognitive characteristics of all HRS decedents enrolled in Medicare FFS and MA plans using χ2 and t test. We performed multivariable ordinal regressions to determine if demographic differences between the Medicare groups explained differences in health, functional, and cognitive status. We used multiple imputation for missing data. The study was exempt from institutional review board approval because the data looked only at decedents. There were no significant differences in results of multivariable analyses using imputed or nonimputed variables (Table 1).
Of the 9385 decedents included in our analysis, 2280 (24.3%) were continuously enrolled in MA plans for the last 6 months of life and 7105 (75.7%) were continuously enrolled in Medicare FFS. The FFS beneficiaries were significantly older than MA beneficiaries at the time of death, and the 2 groups differed with respect to marital status, race, net worth, and educational attainment (Table 1). The MA decedents were less likely to have supplemental insurance compared with FFS decedents, including Medicaid or private insurance. The MA decedents were more likely to be living in urban areas and in the Northeast or West, whereas FFS decedents resided commonly in the Midwest and South. The MA and FFS decedents did not differ in having an advance directive or having discussed their EOL treatment preferences with their health care proxy.
At their last survey before death, FFS beneficiaries were more likely than MA beneficiaries to rate their health as “poor,” to have limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL), and to have dementia. After adjusting for demographic differences between FFS and MA decedents in our sample, differences between FFS and MA decedents in self-rated health, functional limitations, and cognitive status remained significant (Table 2).
The FFS beneficiaries were sicker than MA beneficiaries during the last year of life, with worse functional status, higher rates of dementia, and poorer self-rated health. These are important considerations because policymakers and researchers consider patient-specific factors related to high EOL costs in the Medicare population. Because MA beneficiaries are, on average, younger and more independent at the EOL, their health care utilization and costs may differ from those enrolled in FFS. Prior research6 shows that MA beneficiaries have lower inpatient and Emergency Department utilization at the EOL, and increased hospice enrollment compared with FFS beneficiaries. This pattern may arise from improved EOL management by MA plans but could also reflect a less chronically impaired population, with fewer acute care needs at the EOL owing to better social support and functional and cognitive status.