• Joan M Teno, Thomas J Christian, Pedro Gozalo, and Michael Plotzke.
• 1 Division of Gerontology and Geriatric Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.
• J Palliat Med. 2018 Mar 1; 21 (3): 302-306.

BackgroundWhen Medicare Advantage (MA) patients elect hospice, all covered services are reimbursed under the Medicare fee-for-service (FFS) program. This financial arrangement may incentivize MA plans to refer persons to hospice near end of life when costs of care typically rise.ObjectiveTo characterize hospice discharge patterns for MA versus FFS patients and examine whether patterns differ by MA concentration across hospital referral regions (HRRs).Design And MeasurementThe rate and pattern of live discharges and length of stay (LOS) between FFS and MA patients were examined. A multivariate mixed-effects model examined whether hospice patients in MA versus FFS had differential patterns of discharges. In addition, we tested whether concentrations of MA hospice patients in a patient's HRR were associated with different patterns of discharges.ResultsIn fiscal year 2014, there were 1,199,533 hospice discharges with 331,142 MA patients having a slightly higher live discharge rate (15.8%) compared to 868,391 FFS hospice discharges (15.4%). After controlling for patient characteristics, the adjusted odds ratio (AOR) was 1.01 (95% CI 0.99-1.02). MA patients were less likely to have early live discharges (AOR 0.87 95% CI 0.84-0.91) and burdensome transitions (AOR 0.61 95% CI 0.58-0.64) but did not differ in live discharges post 210 days. Among hospice deaths, MA hospice patients were less likely to have a three-day or less LOS (AOR 0.95 95% 0.94-0.96) and a LOS exceeding 180 days (AOR 0.97 95% 0.96-0.99). The concentration of MA patients in a HRR had minimal impact.ConclusionMA hospice patients' discharge patterns raised less concerns than FFS.

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