INTRODUCTION
Medicare Advantage (MA) has the potential to improve end-of-life care for Medicare beneficiaries.1–3 Evidence suggests that MA enrollment decreases deaths in hospitals and increases deaths while receiving hospice services compared to traditional Medicare.3 The Centers for Medicare and Medicaid Services has implemented a 5-star quality rating system to encourage MA insurers to improve care quality. Since 2014, MA contracts with 4 stars or higher have received additional quality bonus payments, but there is evidence that the MA quality bonus program does not lead to improvements in overall quality of care.4 This raises concerns about the validity of the MA star rating system, leading to an ongoing discussion about how to redesign the quality performance system. However, it remains unknown whether highly-rated MA contracts provide high-quality end-of-life care. In this study, we examined whether enrollment in highly-rated MA contracts was associated with improved end-of-life care among MA decedents. We focused on patterns of end-of-life care in hospital and hospice settings.
METHODS
We used data from multiple sources for 2015-2016: the Medicare Master Beneficiary Summary File, the Medicare Provider Analysis and Review, hospice claims data, and the MA Landscape Source File. This study was approved by the University of Pennsylvania’s institutional review board.
We included MA enrollees (aged 66 years and older) with 12 months of continuous enrollment during the last year of life who died in 2016. As our goal is to compare end-of-life care between those in highly-rated and lowly-rated MA contracts, we limited the sample to those in 2.5-3 and 4.5-5 star contracts, which consist of the bottom and top 20% of the overall star rating distribution.5 Outcomes included care setting at time of death (hospital without hospice care and under hospice care), care received in the last 30 days of life (hospitalization, hospital days, hospice use, hospice days, and hospice use after hospitalization), and care intensity during hospitalization in the last 30 days of life (intensive care unit, non-invasive mechanical ventilation, and invasive mechanical ventilation).
Star ratings may reflect the composition of enrollees rather than the quality of care.6 To account for selective enrollment into highly-rated MA contracts, we computed the inverse probability of treatment weighting (IPTW) as a propensity for enrolling in a 4.5-5 star contract based on control variables (age, sex, race/ethnicity, Medicare-Medicaid dual eligibility, Hierarchical Condition Category risk scores, the month of death, and state ).7 We examined the difference in outcomes among MA enrollees in 4.5-5 star contracts relative to MA enrollees in 2.5-3 star contracts using a linear regression model after applying the IPTW. P values were from 2-sided tests, and results were deemed significant at P < .05.
RESULTS
Our sample included 48130 and 170236 MA enrollees in 2.5-3 and 4.5-5 star contracts, respectively (Table 1). Sample characteristics were similar by star ratings after applying IPTW. We found no or small significant differences in care setting at the time of death and place of care during last 30 days of life between those in 2.5-3 and 4.5-5 star contracts (Table 2). However, those in 4.5-5 star contracts were 13.01 (95% CI: −16.18, −9.83) and 3.84 (95% CI: −6.70, −0.98) percentages points less likely to receive intensive care unit care and invasive mechanical ventilation in the last 30 days of life than those in 2.5-3 star contracts.
Table 1.
Sample characteristics of Medicare Advantage decedents by star rating before and after inverse probability treatment weights.
| Before matching | After matching | |||
|---|---|---|---|---|
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|
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| Characteristics | 2.5-3 star contracts, N (%) | 4.5-5 star contracts, N (%) | 2.5-3 star contracts, % | 4.5-5 star contracts, % |
| Number of enrollees | 48130 | 170236 | ||
| Age | ||||
| 66-69 | 5639 (11.7) | 12747 (7.5) | 8.6 | 8.3 |
| 70-74 | 8342 (17.3) | 22039 (12.9) | 13.5 | 13.9 |
| 75-79 | 8487 (17.6) | 26260 (15.4) | 15.2 | 15.9 |
| 80-84 | 8639 (17.9) | 31270 (18.4) | 18.1 | 18.1 |
| 85+ | 17024 (35.4) | 77920 (45.8) | 44.6 | 43.8 |
| Female | 25649 (53.3) | 88888 (52.2) | 53.0 | 52.3 |
| Race/ethnicity | ||||
| White | 32341 (67.2) | 148018 (86.9) | 86.1 | 84.4 |
| Black | 11826 (24.6) | 12762 (7.5) | 9.1 | 10.0 |
| Hispanic | 1706 (3.5) | 3298 (1.9) | 2.0 | 1.8 |
| Asian/Pacific Islander | 1069 (2.2) | 2626 (1.5) | 1.2 | 1.6 |
| American Indian/Alaska Native | 122 (0.3) | 261 (0.2) | 0.3 | 0.2 |
| Other | 892 (1.9) | 2672 (1.6) | 1.0 | 1.6 |
| Unknown | 175 (0.4) | 599 (0.4) | 0.3 | 0.4 |
| Dual eligibility for Medicare and Medicaid | 16753 (34.8) | 23257 (13.7) | 14.0 | 15.9 |
| HCC risk score | ||||
| 0-0.299 | 15283 (31.8) | 47058 (27.6) | 31.7 | 29.6 |
| 0.3-0.499 | 1913 (4.0) | 7360 (4.3) | 6.2 | 4.4 |
| 0.5-0.999 | 3839 (8.0) | 16728 (9.8) | 10.6 | 9.6 |
| 1-1.999 | 7631 (15.9) | 31161 (18.3) | 16.6 | 17.8 |
| >=2 | 19465 (40.4) | 67929 (39.9) | 34.9 | 38.6 |
Abbreviation: MA, Medicare Advantage; HCC, hierarchical condition category
Table 2.
Differences in care setting at time of death, place of care, and care intensity during hospitalization among Medicare Advantage decedents by star rating.
| Outcomes | 2.5-3 star contracts | 4.5-5 star contracts | Adjusted difference from those in 4.5-5 star contracts to those in 2.5-3 star contracts, percentage points (95% CI) |
|---|---|---|---|
| Care setting at time of death | |||
| Hospital without hospice care, N (%) | 7452 (12.7) | 22832 (13.3) | −0.16 (−1.51 to 1.18) |
| Under hospice care, N (%) | 21016 (51.8) | 91655 (52.6) | 1.39 (−0.49 to 3.28) |
| Place of care during last 30 days of life | |||
| Hospitalization, N (%) | 16494 (30.8) | 54778 (31.8) | −0.56 (−2.23 to 1.11) |
| Hospital days, mean (SD) | 9.6 (7.4) | 8.8 (6.9) | −0.60 (−1.13 to −0.06) |
| Hospice use, N (%) | 21804 (53.2) | 93397 (53.7) | 0.98 (−0.84 to 2.80) |
| Hospice days, mean (SD) | 19.6 (15.8) | 21.0 (16.4) | 1.40 (0.69 to 2.11) |
| Hospice use after hospitalization, N (%) | 6799 (13.7) | 26602 (15.3) | 1.05 (−0.44 to 2.54) |
| Care intensity during hospitalization (conditional on hospitalization) | |||
| ICU, N (%) | 8573 (57.4) | 22996 (43.4) | −13.01 (−16.18 to −9.83) |
| Non-invasive mechanical ventilation, N (%) | 1864 (11.3) | 4802 (8.9) | −1.53 (−4.42 to 1.37) |
| Invasive mechanical ventilation, N (%) | 5145 (27.6) | 12052 (22.9) | −3.84 (−6.70 to −0.98) |
Abbreviation: MA, Medicare Advantage, ICU, intensive care unit.
DISCUSSION
Our findings suggest that MA quality ratings exhibit limited association with the quality of end-of-life care. Particularly, highly-rated MA contracts were not associated with improved access to hospice. Once hospitalized, however, highly-rated MA contracts provide less intensive end-of-life care. As highly-rated MA contracts establish networks with highly-rated providers, this suggests that provider networks are a pathway used by MA contracts to improve outcomes.8,9 The findings should be interpreted within several limitations. There may be selection into highly-rated MA contracts. Although we accounted for differences in sample characteristics, unobserved differences in enrollee-level characteristics may have remained.
Our findings provide critical policy implications. As the current quality rating system does not factor in measures for end-of-life care, this generates little incentive for MA contracts to improve the quality of care at the end of life. MA plans do have powerful economic incentives to refer persons to hospice under the current “hospice carve-out” policy, and likely lack explicit hospice networks. If a decision is made to carve hospice into MA programs, it is important that quality measures are created and used in star ratings to provide consumers and health care providers with critical information on the quality of MA plans in the care of the seriously ill and dying.
ACKNOWLEDGEMENTS
All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals.
Financial support:
This work was supported by the National Institute of Aging, the National Institutes of Health (R01AG062595).
Sponsor’s role:
The National Institutes of Health had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript to submit for publication.
Footnotes
Conflict of interest:
None
Disclosure:
The manuscript, as submitted or its essence in another version, is not under consideration for publication elsewhere, and will not be published elsewhere while under consideration.
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