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Service Use at the End-of-Life in Medicare Advantage Versus Traditional Medicare

Stevenson, David G. PhD*; Ayanian, John Z. MD, MPP†,‡,§; Zaslavsky, Alan M. PhD; Newhouse, Joseph P. PhD†,§,∥,¶; Landon, Bruce E. MD, MBA†,#

doi: 10.1097/MLR.0b013e3182a50278
Original Articles

Background: Relative to traditional fee-for-service Medicare, managed care plans caring for Medicare beneficiaries may be better positioned to promote recommended services and discourage burdensome procedures with little clinical value at the end of life.

Objective: To compare end-of-life service use for enrollees in Medicare Advantage health maintenance organizations (MA-HMO) relative to similar individuals enrolled in traditional Medicare (TM).

Research Design, Subjects, Measures: For a national cohort of Medicare decedents continuously enrolled in MA-HMOs or TM in their year of death, 2003–2009, we obtained hospice enrollment information and individual-level Healthcare Effectiveness Data and Information Set utilization measures for MA-HMO decedents for up to 1 year before death. We developed comparable claims-based measures for TM decedents matched on age, sex, race, and location.

Results: Hospice use in the year preceding death was higher among MA than TM decedents in 2003 (38% vs. 29%), but the gap narrowed over the study period (46% vs. 40% in 2009). Relative to TM, MA decedents had significantly lower rates of inpatient admissions (5%–14% lower), inpatient days (18%–29% lower), and emergency department visits (42%–54% lower). MA decedents initially had lower rates of ambulatory surgery and procedures that converged with TM rates by 2009 and had modestly lower rates of physician visits initially that surpassed TM rates by 2007.

Conclusions: Relative to comparable TM decedents in the same local areas, MA-HMO decedents more frequently enrolled in hospice and used fewer inpatient and emergency department services, demonstrating that MA plans provide less end-of-life care in hospital settings.

Supplemental Digital Content is available in the text.

*Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN

Department of Health Care Policy, Harvard Medical School

Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital

§Department of Health Policy and Management, Harvard School of Public Health, Boston

Harvard Kennedy School

National Bureau of Economic Research, Cambridge

#Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by a grant from the National Institute on Aging (P01 AG032952). D.G.S. was supported by a career development grant from the National Institute on Aging (K01 AG038481 and by a gift from Susan Levine and the Hospice of the Valley Foundation).

John Z. Ayanian and Bruce E. Landon are consultants to RTI International on the development of statistical risk adjustment models for CMS to adjust payments to Medicare Advantage plans. Joseph P. Newhouse is a director of and holds equity in Aetna, which sells Medicare Advantage plans; he is also a director of the National Committee for Quality Assurance, which owns and maintains HEDIS® measures.

Reprints: David G. Stevenson, PhD, Department of Health Policy, Vanderbilt University Medical Center, 2525 West End Avenue, Nashville, TN 37203. E-mail:

© 2013 by Lippincott Williams & Wilkins.