Hospice Enrollment from Community Setting More Common in Medicare Advantage

Medicare Advantage beneficiaries were more likely to enroll in hospice from a community setting rather than a hospital or nursing home setting compared to traditional Medicare beneficiaries, according to a study published in JAMA Health Forum.

Hospice enrollment among Medicare beneficiaries has increased significantly over the past two decades. Late hospice referral has been associated with lower satisfaction, unmet needs, and higher levels of hospitalization and intensive care use in the last month of life.

Late referrals often occur from hospital settings, raising the question of how hospice care differs depending on the site of care prior to hospice referral.

Medicare Advantage enrollment might also affect the pathway to hospice. Medicare Advantage beneficiaries have historically enrolled in hospice at higher rates than traditional Medicare beneficiaries.

Researchers used Medicare claims data from 2011, 2013, 2016, and 2018 for decedents who enrolled in hospice in the last 90 days of life to compare prior care sites among Medicare Advantage and traditional Medicare beneficiaries.

The study specifically focused on whether Medicare Advantage beneficiaries in hospice were more likely to enroll from the community over hospital or nursing home settings.

The final sample included 3,164,959 decedents who enrolled in hospice. Nearly 30 percent of the decedents were enrolled in Medicare Advantage. Among individuals in traditional Medicare, 48.9 percent enrolled in hospice compared to 52.8 percent of those in Medicare Advantage.

Medicare Advantage beneficiaries were more likely to enroll in hospice from community settings than traditional Medicare beneficiaries, the study found.

In 2011, 50.1 percent of Medicare Advantage beneficiaries in hospice enrolled from the community, compared to 39 percent of those in traditional Medicare, indicating an 11.1 percent higher rate of community enrollment in Medicare Advantage.

This gap narrowed slightly across the study period to 8.1 percent in 2018, when 46.4 percent of Medicare Advantage beneficiaries in hospice enrolled from the community compared to 38.3 percent of traditional Medicare beneficiaries.

Decedents in Medicare Advantage had an 8.09 percentage point higher rate of hospice enrollment from the community than those in traditional Medicare.

Similarly, decedents who switched between the two programs and remained in Medicare Advantage during the last year of life had an 8.1 percentage point higher rate of community hospice enrollment compared to those who stayed in traditional Medicare.

Individuals who joined Medicare Advantage in the last year of life had a 5.2 percentage point higher proportion of community hospice enrollment than those who stayed in Medicare Advantage the entire year.

Meanwhile, decedents who left Medicare Advantage had a 3.7 percentage point lower rate of community hospice enrollment compared to those who stayed in Medicare Advantage the whole year.

Individuals who enrolled in hospice from the community were more likely to be male, less likely to be dually eligible for Medicaid, less likely to be non-Hispanic Black, and more likely to have cancer as their primary hospice diagnosis.

The mean length of stay in hospice was shortest for decedents enrolling from acute care hospitals—5.9 days in traditional Medicare in 6 days for Medicare Advantage. Length of stay was the longest for those enrolling from the community without home health—10.7 days in traditional Medicare and 10.2 days in Medicare Advantage.

Medicare Advantage enrollment was associated with a 0.29-day longer hospice stay compared with traditional Medicare enrollment.

Hospice benefits in Medicare Advantage are paid for as part of traditional Medicare. Thus, Medicare Advantage has a greater incentive to identify adults eligible for hospice and steer them toward this care before health changes occur that could lead to hospitalizations.

Active case management for post-acute care utilization may also be correlated with increased hospice enrollment in Medicare Advantage.

Researchers concluded that additional research is warranted to determine why Medicare Advantage beneficiaries were more likely to enroll in hospice from the community.