End-of-Life Care for Older Adults With Blood Cancers With Medicare Advantage Versus Medicare Fee-For-Service Insurance.

Abstract

Purpose: Adults with hematologic malignancies (HMs) often experience suboptimal end-of-life (EOL) care, with patients from minoritized racial/ethnic groups at even greater risk. It is unclear whether these disparities are partly driven by modifiable factors such as insurance.

Methods: Using the Centers for Medicare and Medicaid Services database, we compared the quality of EOL care as defined by hospice use, high-intensity health care utilization, and advance care planning between Medicare advantage (MA) and Medicare fee-for service (FFS) insurance among patients with HM 66 years and older who died between 2016 and 2020. Multivariate analysis was used to compare EOL care outcomes.

Results: The study included 23,130 patients with MA and 46,145 with FFS. Compared with FFS, MA beneficiaries were more likely to be Black (11.1% v 7.8%; P < .001) or Hispanic (8.3% v 4.3%; P < .001). MA was associated with higher odds of hospice enrollment (odds ratio [OR], 1.11; 95% CI, 1.08 to 1.15) and decreased odds of hospice stays ≤7 days (OR, 0.94; 95% CI, 0.90 to 0.98). Compared with FFS, MA beneficiaries had lower odds of ≥2 emergency department visits (OR, 0.80; 95% CI, 0.76 to 0.84) or intensive care unit stays (OR, 0.83; 95% CI, 0.80 to 0.86) in the last month of life and lower odds of in-hospital death (OR, 0.74; 95% CI, 0.71 to 0.77).

Conclusion: In this large cohort of HM decedents, MA insurance was associated with greater hospice use and lower rates of high-intensity health care utilization near the EOL compared with FFS, despite being more likely to have beneficiaries of color. This suggests that insurance type may affect the quality of EOL care and partly mitigate existing disparities. Future work characterizing which elements of insurance promote high-quality EOL care may help to improve equitable access to such care.