*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.
Med Care. 2013 Oct;51(10):931-7. doi: 10.1097/MLR.0b013e3182a50278.
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.
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.
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.
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.
与传统的按服务收费的医疗保险相比，管理式医疗保健计划在照顾医疗保险受益人方面可能更有优势，可以更好地推广推荐的服务，并在生命末期减少没有临床价值的繁琐程序。
比较医疗保险优势健康维护组织（MA-HMO）参保人与类似的传统医疗保险（TM）参保人在生命末期的服务使用情况。
研究设计、对象和措施：对于 2003 年至 2009 年期间连续参加 MA-HMO 或 TM 的全国性医疗保险死亡者队列，我们获得了 MA-HMO 死者的临终关怀登记信息和个人层面医疗保健效果数据和信息集使用情况的信息，最多可追溯到死亡前一年。我们为 TM 死者开发了基于索赔的可比措施，这些死者按年龄、性别、种族和地点进行了匹配。
2003 年，MA 死者在死亡前一年接受临终关怀的比例高于 TM 死者（38%比 29%），但这一差距在研究期间缩小（2009 年为 46%比 40%）。与 TM 相比，MA 死者的住院入院率（低 5%-14%）、住院天数（低 18%-29%）和急诊就诊率（低 42%-54%）显著降低。MA 死者最初的门诊手术和程序率较低，但到 2009 年与 TM 率趋同，最初的医生就诊率略低于 TM 率，但到 2007 年超过了 TM 率。
与相同当地地区的可比 TM 死者相比，MA-HMO 死者更频繁地参加临终关怀，使用的住院和急诊服务较少，这表明 MA 计划在医院环境中提供的临终关怀较少。
