Increasingly, older Americans are likely to die at home, and not in a hospital. And more seniors are using hospice care as they near end of life. However, stubbornly large numbers of Medicare beneficiaries still land in intensive care units or find themselves shuttled from home to hospital and back again in their last months of life.
A fascinating and important new paper from Joan Teno and colleagues published in the Journal of the American Medical Assn (requires registration) also finds that those enrolled in traditional Medicare fee-for-service plans have different experiences from those who participate in Medicare Advantage (MA) managed care. MA enrollees are more likely than traditional Medicare beneficiaries to die at home, less likely to spend time in a hospital or nursing home in their last months of life, and less likely to be moved from nursing homes to hospitals and back as they near death.
The best news
The researchers looked at trends in location and types of care for traditional Medicare patients over 15 years, from 2000 to 2015. They studied the experiences of those in the newer MA plans in 2011 and 2015. They used a sample of 20 percent of all Medicare beneficiaries who died during the study period.
Both the overall percentages and the trends tell important stories to consider as we think of how we want to live in our last months.
The best news: The authors found a steady decline in the percentage of Medicare enrollees who died in the hospital. In 2000, about one-third passed away in an acute care hospital. By 2015, fewer than one-in-five did so. At the same time, the share of those dying at home (including assisted living facilities) rose from 30 percent to 40 percent. MA enrollees were even more likely to die at home, with nearly half doing so in 2015.
However, even though seniors were less likely to die in a hospital, it doesn’t mean they were not being admitted to hospitals and spending time in intensive care units as they neared end of life.
ICUs and nursing homes
In 2015, about 54 percent of traditional Medicare patients were hospitalized sometime in their last 30 days of life, and 66 percent were admitted to a hospital sometime during their last 90 days, percentages that were somewhat higher than in 2000.
The experience of MA patients was different. In 2015, they were about 10 percentage points less likely to be hospitalized during their last 30 or 90 days of life.
The pattern was similar for ICUs and nursing homes. For fee-for-service Medicare, the share of ICU users went up from about 24 percent in 2000 to 29 percent in 2015, while the share admitted to a nursing home rose slightly from just under 43 percent.
Among MA enrollees, about 27 percent spent time in an ICU and about one-third were admitted to a nursing home.
Finally, the researchers look at what they called “potentially burdensome care,” including more than three hospitalizations in the last 90 days of life, multiple hospitalizations for infections or dehydration over the last six months of life, or moving from one care site to another in the three days before death.
For example, they found that in 2015, about 7 percent of fee-for-service patients were hospitalized at least three times in their last three months, down from 10 percent in 2000, but about 1 percentage point more than MA participants. The share of those repeatedly hospitalized for infections or dehydration dropped from about 15 percent in 2000 to about 12 percent in 2015 for traditional Medicare. About 10.5 percent of MA plans had this experience in 2015.
Interestingly, for many of these indicators, the researchers found that the shares bumped up in 2009, then declined.
What’s happening with MA
The authors don’t try to explain these patterns. As they say, “It is difficult to disentangle efforts such as public education, promotion of advanced directives…[and] increased access to hospice and palliative care services.”
Nor do they try to explain the differences in experience between fee-for-service Medicare and Medicare managed care. And the lesson people take away from these data probably depends on their prior attitudes about managed care.
Critics of MA plans would probably say that their enrollees were not hospitalized because the plans were reluctant to spend money on patients who were close to death or, worse, those patients died because they did not get the medical care they needed.
But there is another, more positive story: There is growing evidence that intense treatment at the end of life and movement from one care setting to another harms patients and their families, and often is contrary to the wishes of many older adults. In that case, the financial incentives in managed care that discourage use of hospital or nursing home stays at the end of life may be well aligned with the needs and wishes of patients.
It will take some time to answer those questions. But the work of Teno and her colleagues provides some important information for all of us.