Comparing End-of-Life Home Health and Hospice Use in Medicare Advantage vs. Traditional Medicare among Decedents with Dementia

PROJECT SUMMARY/ABSTRACT Medicare Advantage (MA) plans increasingly shape the care of older adults with functional disability, and in particular those with advanced Alzheimer’s Disease and Alzheimer’s Disease Related Dementias (AD/ADRD). Indeed, in 2021, 42% of Medicare beneficiaries are enrolled in MA plans. However, we know little about quality of care delivery and outcomes within the MA program. MA is unique from traditional Medicare in that a private health company is paid a set rate by Medicare, and then can offer more flexible benefits and cost-sharing to enrollees, albeit also employing structures such as limited provider networks and prior authorization requirements for treatments to control costs. Preliminary research, including that done during my K76 Paul B. Beeson Emerging Leaders Career Development Award in Aging, has found that older adults are more likely to leave MA for traditional Medicare after the onset of functional disability, and the family and friends of decedents in MA plans report lower quality of end-of-life care. This raises the question of how MA plans are delivering services that are important to community-dwelling older adults with advanced AD/ADRD, such as home health and hospice. My prior work has found that older adults with AD/ADRD not only rely on high levels of these services, but use home health differently than their counterparts without AD/ADRD. It is unclear how enrollment in MA shapes these use patterns, although pilot data within the National Health and Aging Trends Study indicates that decedents with AD/ADRD in MA plans may receive less home health than their counterparts in traditional Medicare. Not only is it uncertain if this is true in a larger cohort, but also is it unknown how differences between MA plans, such as the plan type and the degree to which older adults with AD/ADRD are enrolled in the plan, shapes home health and hospice use. This Alzheimer’s-focused administrative supplement will allow me to expand my current work, supported by the K76 Paul Beeson Emerging Leaders Career Development Award in Aging, in order to gain the scientific skills to develop as an AD/ADRD researcher working to improve Medicare delivery while addressing the following specific aims: in SA1, I will compare patterns of home health and hospice use in the last year of life between decedents with AD/ADRD in MA vs. traditional Medicare; in SA2, I will assess if MA plan type and the concentration of older adults with AD/ADRD within the MA plan influences patterns of home health and hospice use in the last year of life. This 1-year project will fill a scientific gap in our understanding of the role of MA plans in shaping the care of older adults with AD/ADRD in the last year of life. It will provide preliminary data that will inform my planned R01 proposal examining further patient outcomes and drivers of high-quality care at the end of life in MA plans, with a focus on decedents with AD/ADRD. Given the growing influence of MA on older adults with AD/ADRD as well as our broad need to understand how to best support this population as they age in the community, this proposed supplement is timely to improve care for older adults with AD/ADRD.