Medicare Advantage Enrollees Use Less End-of-Life Home Health Care, Study Finds

End-of-life home health use and duration were lower in Medicare Advantage (MA) enrollees vs traditional Medicare (TM) enrollees for nearly all populations, especially among Hispanic and Asian or Pacific Islander decedents, according to a research letter published in JAMA Network Open.1

Medicare-funded home health provides critical support to homebound adults who require skilled care through social work, nursing, rehabilitation, and aid visits. It is particularly relevant for Hispanic and non-Hispanic Black older adults, who access hospice services at lower rates than White adults.

The researchers noted that MA enrollees, who are disproportionately from racially or ethnically minoritized communities, are less likely to receive home health and use fewer days of services than TM enrollees. Therefore, they conducted a study to assess whether MA enrollment was associated with greater racial and ethnic disparities in home health use during the last year of life compared with TM enrollment.

Medicare Advantage (MA) enrollees, particularly Hispanic and Asian or Pacific Islander decedents, use less end-of-life home health care than those enrolled in traditional Medicare (TM). | Image Credit: Rido - stock.adobe.com

They used the 2018-2019 Master Beneficiary Summary File (MBSF) to identify US adults aged 66 or older who died in 2019 and had Medicare coverage during their last year of life.2 The study population included individuals potentially eligible for home health use during their last year of life.1 However, this group did not reside in a nursing facility or hospital, nor were they enrolled in hospice.

Using the MBSF, the researchers identified the eligible participants enrolled in MA vs TM 1 year before death. They also extracted data on race and ethnicity, dual eligibility status, sex, age, and the reason for original Medicare entitlement. Additionally, home health use and its duration were assessed using the 2018-2019 Outcome and Assessment Information Set files, with time adjusted to 365 potentially eligible days, meaning those not spent in a nursing facility, hospital, or enrolled in hospice.

Linear probability models were employed to compare the proportion of decedents receiving home health care during the last year of life. These were also used to evaluate the number of days of home health use among individuals in MA vs TM; they mainly focused on use in terms of race and ethnicity.

The researchers identified 1,787,084 decedents, with a mean (standard deviation [SD]) age of 82.0 (8.9) years. Most (51.5%) decedents were female, and 36.5% were MA enrollees. The overall adjusted rate of home health use was 37.5% in MA enrollees and 41.7% in TM enrollees, equating to a 4.2% lower rate among MA enrollees (95% CI, 4.1-4.3).

When stratified by race and ethnicity, home health use remained lower in MA than TM for most groups; however, among American Indian or Alaska Native decedents, MA enrollees had slightly higher use. Therefore, the rate of home health use among American Indian or Alaska Native decedents was 37.9% in MA vs 37.1% in TM, a 0.8% higher rate for MA (95% CI, 1.7-3.4).

Conversely, among Asian or Pacific Islander decedents, the rate was 32.6% for MA compared with 41.8% for TM, equating to a 9.2% lower rate for MA (95% CI, 8.4-10.1). Similarly, the rate of home health use among Hispanic decedents was 33.0% for MA vs 44.0% for TM, a 10.8% lower rate for MA (95% CI, 10.2-11.3).

As for non-Hispanic Black decedents, the rate was 38.8% for MA compared with 42.9% for TM, a 4.1% lower rate for MA (95% CI, 3.6-4.5). Among non-Hispanic White decedents, it was 37.9% for MA vs 41.5% for TM, a 3.6% lower rate for MA (95% CI, 3.4-3.7). Lastly, for decedents of other or unknown race, the rate was 36.1% for MA compared with 40.1% for TM, a 4.0% lower rate for MA (95% CI, 2.7-5.2).

Overall, home health users across all racial and ethnic groups had fewer home health days in MA than in TM. This difference was especially pronounced among Hispanic decedents, who averaged 81.9 days in MA vs 111.9 days in TM, representing a 30-day difference (95% CI, 27.7-32.2) per 365 eligible days.

The researchers acknowledged their study’s limitations, one being that it relied on pre-pandemic data due to the influence of the COVID-19 pandemic on home-based care. However, they expressed confidence in their findings, using them to suggest areas for further research.

“Future research needs to examine the mechanisms of these differences, including the characteristics of MA plans that older adults enroll in and how they influence home health use,” the authors concluded.

References

1. Jones T, Vargas-Torres C, Meyers DJ, Morrison RS, Ankuda CK. Racial disparities in end-of-life home health use in Medicare Advantage vs traditional Medicare. JAMA. Published online January 27, 2025. doi:10.1001/jama.2024.27493
2. Master Beneficiary Summary File (MBSF) LDS. CMS. Updated September 10, 2024. Accessed January 30, 2025. https://www.cms.gov/data-research/files-for-order/limited-data-set-lds-files/master-beneficiary-summary-file-mbsf-lds