Why Traditional Medicare Should Ensure MA Plans Are Addressing Quality of Care at End-of-Life

^{By Julie Gould} 

A study published online in JAMA Network Open, shows that family and friends of people who died while enrolled in Medicare Advantage (MA) reported lower quality of care in the last month of life compared with family and friends of those who died while enrolled in traditional Medicare. 

“MA insures an increasing proportion of Medicare beneficiaries, but evidence is lacking on patient or family perceptions of the quality of end-of-life care in MA vs traditional Medicare,” the study authors wrote. 

To better understand why this research was conducted, the study design, and the findings, we spoke with lead author Claire Ankuda, MD, MPH, assistant professor, Brookdale Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai.  

What existing data led you and your co-investigators to conduct this research?

Growing numbers of older adults are insured through Medicare Advantage (MA) plans, where they can receive lower cost care than in Traditional Medicare (TM) as well as some expanded benefits, whether that is dental care or hearing aides or help with transportation to doctor visits.  However, there’s a lot we don’t know about the quality of care in MA, especially for older adults with serious illness who are at the end of life.  A growing body of data has raised concerns about quality for people who are this sick: people with high health care needs are more likely to switch from MA to TM, for example.  In addition, one way that MA works is to limit care providers to a specified network and research has found that the nursing facilities and home health agencies that are in MA networks tend to be lower quality compared to facilities not in MA networks.  All of this has raised concerns about quality of care at the end of life, which is of course really best measured by what patients and their families tell us about quality of care. 

Please briefly describe your study and its findings. Were any of the outcomes particularly surprising?

We looked at a national survey of older adults. In this survey, the friends and family of people who die are interviewed about their last month of care, including things like the quality of care and communication.  We looked to see if the friends and family of people enrolled in MA plans describe lower quality of care.  We found that, even adjusting for the differences in the populations between those in MA and TM at the end of life, the friends and family of those in MA plans were LESS likely to report that care was excellent and MORE likely to report that they were not kept informed over the person’s last month of life.  In other words, they reported worse quality of end of life care for people who were in MA at the end of life.  This gap in quality seemed to be particularly large among those who were cared for in nursing homes at the end of life- with care much worse in MA plans compared to TM- but that result wasn’t statistically significant. 

What are the possible real-world applications of these findings in clinical practice?

It’s clear we need far more data on quality in MA plans, especially for our sickest patients who are really vulnerable to being impacted by low quality care. We need to make sure that quality is measured by the direct reports of patients and their caregivers, especially at the end of life.  We certainly need to understand why these care gaps exist, and potentially monitor the networks of nursing facilities that MA plans send patients to if that is the driver of this quality gap.  

Do you and your co-investigators intend to expand upon this research?

Yes. We have more work underway to assess how MA plans are shaping the care and caregiving of older adults with serious illness. 

About Dr Ankuda

Claire Ankuda, MD, MPH, is an Assistant Professor at the Brookdale Department of Geriatrics and Palliative Care at the Icahn School of Medicine at Mount Sinai. She is a health services researcher and palliative care clinician who studies how Medicare policies shape the care of older adults with serious illness. 

Reference:

Ankuda CK, Kelley AS, Morrison RS, Freedman VA, Teno JM. Family and Friend Perceptions of Quality of End-of-Life Care in Medicare Advantage vs Traditional Medicare. JAMA Netw Open. 2020;3(10):e2020345. Published 2020 Oct 1. doi:10.1001/jamanetworkopen.2020.20345