Older Age, Minority Status Influence Advance Care Planning Among Medicare Enrollees

A new study published in JAMA Internal Medicine that examined the rate of advance care planning (ACP) among Medicare beneficiaries found that more than 25% of older adults have not engaged in planning for end-of-life (EOL) care or advance directives. A significant determinant of lack of planning, according to study authors from the University of Southern California (UCSF), was income, level of education, and race.

The retrospective analysis used 2012 data from the National Health and Aging Trends Study (NHATS), which used a nationally representative sample of community-dwelling Medicare beneficiaries, over 65 years of age who live in their own communities. The authors had self-reported beneficiary information on age, gender, race/ethnicity, education, income, self-rated health, number of chronic conditions, disability in activities of daily living, and dementia.

Of the more than 2100 participants who responded to a NHATS ACP module, 60% confirmed having had EOL discussions, 50% had discussions on durable power of attorney, and 52% said they had discussions on advance directives. However, 27% reported they had not had discussions on any of the ACP elements. A significant influence of race, income, and education was obvious from the study results: the prevalence of discussions was lower among African Americans and Latinos, and those who were less educated and belonged to the lower-income group.

The authors report that older Spanish-speaking Latinos were the least involved in either of the 3 elements of ACP: 19% stated they had discussions on EOL, 20% on durable power of attorney, and 17% on advance directives.

A significant finding of the study was the lack of engagement among older adults who might be in much poorer health—only 54% of older adults with dementia had EOL discussions and 46% had advance directives, compared with 62% and 54%, respectively, among those without dementia.

“Despite decades of work to improve advance care planning, over a quarter of older adults have still not engaged in any type of discussion or planning for their end-of-life preferences or plans,” lead author Krista L. Harrison, PhD, geriatrics research fellow at UCSF, said in a statement. “Our findings suggest that there are substantial portions of the population of community-dwelling older adults who need to begin discussions about their plans and preferences before they are unable to share those preferences with their loved ones.”

It has been less than a year since the CMS decision to pay for voluntary ACP under the Medicare Physician Fee Schedule and Hospital Outpatient Prospective Payment System went into effect on January 1, 2016. This change in the payment system will potentially raise awareness among Medicare beneficiaries and modify their attitude.