TY - JOUR
T1 - Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare
AU - Teno, Joan M.
AU - Keohane, Laura M.
AU - Mitchell, Susan L.
AU - Meyers, David J.
AU - Bunker, Jennifer N.
AU - Belanger, Emmanuelle
AU - Gozalo, Pedro L.
AU - Trivedi, Amal N.
N1 - Publisher Copyright:
© 2021 The American Geriatrics Society.
PY - 2021/10
Y1 - 2021/10
N2 - Background/Objective: Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM). Design, Setting, and Participants: Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment. Measurements: Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing. Results: Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70–0.74) among MA enrollees and 1.05 (95% CI 1.02–1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75–0.81) among MA enrollees and 1.02 (95% CI 0.96–1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75–0.85) compared to TM. Conclusions: Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.
AB - Background/Objective: Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM). Design, Setting, and Participants: Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment. Measurements: Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing. Results: Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70–0.74) among MA enrollees and 1.05 (95% CI 1.02–1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75–0.81) among MA enrollees and 1.02 (95% CI 0.96–1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75–0.85) compared to TM. Conclusions: Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.
KW - Accountable Care Organizations
KW - Medicare Advantage plans
KW - dementia
KW - end of life
UR - http://www.scopus.com/inward/record.url?scp=85105947205&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85105947205&partnerID=8YFLogxK
U2 - 10.1111/jgs.17225
DO - 10.1111/jgs.17225
M3 - Article
C2 - 33989430
AN - SCOPUS:85105947205
SN - 0002-8614
VL - 69
SP - 2802
EP - 2810
JO - Journal of the American Geriatrics Society
JF - Journal of the American Geriatrics Society
IS - 10
ER -