Context For most patients aged 65 years or older with cancer, hospice services
are uniformly covered by Medicare. Hospice care is believed to improve care
for patients at the end of life. However, few patients use hospice and others
enroll too late to maximize the benefits of hospice services.
Objectives Because type of insurance may affect use, we examined whether patients
with Medicare managed care insurance enrolled in hospice earlier and had longer
hospice stays than patients with Medicare fee-for-service (FFS) insurance.
Design and Setting Retrospective analysis of the last year of life using the Linked Medicare-Tumor
Registry Database in 1 of 9 Surveillance, Epidemiology, and End Results program
Patients A total of 260 090 Medicare beneficiaries aged 66 years or older
diagnosed with first primary lung (n = 62 117), colorectal (n = 57 260),
prostate (n = 59 826), female breast (n = 37 609), bladder (n =
19 598), pancreatic (n = 11 378), gastric (n = 9599), or liver (n
= 2703) cancer between January 1, 1973, and December 31, 1996, and who died
between January 1, 1988, and December 31, 1998.
Main Outcome Measures Time from diagnosis to hospice entry and hospice length of stay for
patients enrolled in FFS vs managed care plans after adjusting for patient
demographics, tumor registry, year of hospice entry, and type and cancer stage.
Results Of the 260 090 patients, most were men (59%), white (85%), and
enrolled in FFS (89.7%). Only 54 937 patients (21.1%) received hospice
care before death. Hospice use varied by type of primary cancer ranging from
31.8% of patients with pancreatic cancer to 15.6% with bladder cancer. Managed
care patients were more likely to use hospice than FFS patients (32.4% vs
19.8%, P<.001). Among hospice patients, median
(interquartile range) length of stay was longer for managed care vs FFS patients
(32 days [11-82] vs 25 days [9-66], P<.001). After
adjustment, managed care patients had higher rates of hospice enrollment (adjusted
hazard ratio [HR], 1.38; 95% CI, 1.35-1.42) and had a longer length of stay
(adjusted HR, 0.91; 95% CI, 0.88-0.94) vs FFS patients. Managed care patients
were less likely to enroll in hospice within 7 days of their death (18.6%
vs 22.6%, P<.001) and somewhat more likely to
enroll in hospice more than 180 days before death (7.8% vs 6.1%, P<.001); the results for each of the 8 cancer diagnoses were similar.
Hospice enrollment and length of stay among managed care vs FFS patients differed
significantly by region.
Conclusion Medicare beneficiaries enrolled in managed care had consistently higher
rates of hospice use and significantly longer hospice stays than those enrolled
in FFS. Although these differences may reflect patient and family preferences,
our findings raise the possibility that some managed care plans are more successful
at facilitating or encouraging hospice use for patients dying with cancer.