59% MA Plan Proxies Rate End-of-Life Care Quality “Not Excellent”

October 26, 2020 - Responses from families and friends of deceased Medicare Advantage members indicate that Medicare Advantage plans have room for improvement on end-of-life care, a study published in JAMA Network Open found.

“In this cross-sectional study of people who died while enrolled in Medicare, friends and family of those in MA reported lower-quality end-of-life care compared with friends and family of those enrolled in traditional Medicare,” the study stated. “These findings suggest that, given the rapid growth of MA, Medicare should take steps to ensure that MA plans are held accountable for quality of care at the end of life.”

The researchers leveraged data from the National Health and Aging Trends Study (NHATS), which includes an annual survey of beneficiary proxies on their experience of care in the final month of the beneficiary’s life. The study compared answers for proxies of traditional Medicare beneficiaries and Medicare Advantage enrollees from 2011 to 2017.

A proxy is an individual whom a beneficiary has legally designated to make healthcare decisions for the beneficiary when the beneficiary is unable to speak on their own behalf.

“Owing to evidence of individuals with higher need switching from MA to traditional Medicare near end of life, we tested an expanded definition of MA that considered insurance status 12 months before death rather than simply at time of death,” the experts qualified.

The study looked at several areas of patient experience, specifically pain and symptom management, communication and decision-making, emotional support, and overall quality of care.

Proxies for Medicare Advantage members were more likely to give a poor quality of care rating. Roughly 59 percent of Medicare Advantage proxies scored the overall quality of care as not excellent, compared to 53 percent of traditional Medicare proxies.

Proxies for Medicare Advantage or traditional Medicare beneficiaries who had not received hospice care were more likely to score the care as not excellent.

Proxies for Medicare Advantage members whose end-of-life care occurred in a nursing home were far more likely to be unsatisfied with the level of care than proxies for traditional Medicare beneficiaries in the same type of care site.

Nearly eight in ten proxies of Medicare Advantage members who received end-of-life care in nursing homes found that the care was not excellent (77.9 percent), compared to a little less than six in ten proxies of Medicare beneficiaries who received end-of-life care in nursing homes (57.2 percent).

Medicare Advantage proxies were also more likely to state that they were left out of communication in the final month of the beneficiary’s life.

The distinctions between Medicare Advantage and Medicare proxies on issues regarding pain and symptom management, emotional support, and other areas were not significantly different between the two coverage types. However, that does not mean that the plans did well on these measures.

In particular, Medicare Advantage plans and traditional Medicare plans were equally as bad at addressing anxiety or sadness and providing spiritual support.

Demographically, in this study, Medicare Advantage members were less likely to be non-Hispanic White individuals, more often had dementia and lung disease, and were more frequently of lower income, compared to their counterparts in traditional Medicare.

“There are several reasons why perceived quality of care at the end of life may be worse for individuals enrolled in MA,” the researchers stated. “Prior studies have demonstrated the strong influence MA plans have on postacute and institutional care, such as skilled nursing, home health, and nursing home care. MA plans may be restricting their networks to facilities and agencies that are willing to accept lower prices and that consequently may cut staff or other expenses important to the perceived quality of care of these older adults, who are at increased risk.”

The researchers for this study are not the only experts to have observed this trend in low quality of Medicare Advantage care for the seriously ill.

A recent study published in the American Journal of Accountable Care found that seriously ill Medicare beneficiaries often would shift from Medicare Advantage plans to Medicare fee-for-service in order to access the hospice benefit only offered in traditional Medicare.

And a separate 2019 study conducted by the Duke-Margolis Center for Health Policy discovered that  rural communities often do not have access to Medicare Advantage plans’ more advanced benefits, which can be most useful for beneficiaries with a serious illness.

In 2021, most of the Medicare Advantage plans’ supplemental benefits will focus on the “big three”—vision, dental, and hearing benefits—as well as over-the-counter drug (79 percent of plans) and transportation benefits (47 percent of plans).