Abstract
IMPORTANCE: Although enrollment in both hospice care and Medicare Advantage (MA) have grown substantially, little is known about the quality of hospice care received by MA beneficiaries relative to traditional Medicare fee-for-service (FFS) beneficiaries. OBJECTIVE: To compare hospice enrollment and the quality of hospices serving MA and FFS beneficiaries. DESIGN, SETTING, AND PARTICIPANTS: This population-based cross-sectional study used Medicare enrollment and claims data from January 1, 2018, through December 31, 2019, and Hospice Quality Reporting Program (HQRP) data released between November 1, 2020, and August 30, 2022, to compare the probability of enrolling in hospice before death and the probability of using high- vs low-quality hospices between MA and FFS beneficiaries. Two sample populations were assessed: (1) all Medicare beneficiaries who died in 2018 or 2019, and (2) all Medicare hospice enrollees in 2018 and 2019, excluding beneficiaries with hospice use in 2017. Data were analyzed between April 1, 2023, and April 30, 2024. EXPOSURES: MA enrollment was assessed 6 months prior to death for decedents and in the month of hospice admission for hospice enrollees. MA beneficiaries were further classified by plan type: regular MA, special needs plan (SNP), and Medicare-Medicaid plan (MMP). MAIN OUTCOMES AND MEASURES: For decedents, the outcome of interest was the prevalence of any hospice use in the last 6 months of life. For hospice enrollees, the outcome of interest was 9 HQRP measures of hospice quality. RESULTS: Data from 4 215 648 decedents (51.6% female; mean [SD] age, 80.1 [11.6] years) and 2 211 826 hospice enrollees (56.6% female; mean [SD] age, 82.4 [10.5] years) were included. In the decedent sample, beneficiaries enrolled in every type of MA plan were significantly more likely than beneficiaries enrolled in FFS to use hospice care in the last 6 months of life (regular MA beneficiaries were 3.4 percentage points more likely to use hospice; MA SNP beneficiaries, 2.4 percentage points; and MA MMP beneficiaries, 3.6 percentage points). Regular MA and FFS beneficiaries enrolled in hospices of similar quality. However, beneficiaries in SNPs and MMPs were significantly more likely than FFS beneficiaries to use hospices with inferior quality (eg, MA SNP beneficiaries were 4.3 [95% CI, 3.9-4.7] percentage points more likely to use a hospice with a low Consumer Assessment of Healthcare Providers and Systems (CAHPS) global rating, and MA MMP beneficiaries were 6.8 [95% CI, 6.0-7.7] percentage points more likely). When beneficiaries entered hospice from the same hospital or nursing home the results were attenuated: the MA SNP beneficiaries entering from the same hospital were 0.9 (95% CI, 0.5-1.4) percentage points more likely to use a hospice with a low CAHPS global rating, and MA MMP beneficiaries were 3.8 (95% CI, 2.4-5.1) percentage points more likely; MA SNP beneficiaries entering from the same nursing home were 2.8 (95% CI, 2.3-3.3) percentage points more likely to use a hospice with a low CAHPS global rating, and MA MMP beneficiaries were 1.9 (95% CI, 0.9-2.9) percentage points more likely. These results suggest that referral networks were an important mechanism of the hospice quality choice. CONCLUSIONS AND RELEVANCE: These findings suggest that policymakers should consider policies for MA programs that incentivize referrals to high-quality hospices and approaches to educating beneficiaries on identifying high-quality hospice care.