Abstract
Purpose
Although rates of hospice use have increased over time, insurance plan- and racial/ethnic-based disparities in rates have been reported in the USA. We hypothesized that increased rates of hospice use would reduce or eliminate insurance plan-based disparities and that racial/ethnic disparities would be eliminated in managed care (MC) insurance plans.
Methods
We studied the use of hospice care in the final 30 days of life among 40,184 elderly Texas Medicare beneficiaries who died from primary breast, colorectal, lung, pancreas, or prostate cancer between January 1, 2007 and December 31, 2013, using statewide Medicare claims linked to cancer registry data. Rates of hospice use were computed by race/ethnicity and insurance plan (MC or fee-for-service (FFS)). We used logistic regression to account for the impact of confounding factors.
Results
Rates of hospice use increased significantly over time, from 68.9% in 2007 to 76.1% in 2013. By 2013, differences in hospice use rates between MC and FFS plans had been reduced from 10% to < 5%. However, after accounting for insurance plan and confounding factors, racial/ethnic minority beneficiaries’ hospice use was significantly lower than non-Hispanic white beneficiaries’ (p < 0.0001). This disparity was observed among both FFS and MC beneficiaries.
Conclusions
Hospice use in the final 30 days of life has increased among elderly cancer patients in Texas, virtually eliminating the difference between FFS and MC insurance plans. Despite these positive trends, racial/ethnic-based disparities persist. These disparities are not explained by confounding factors. Future research should address social and behavioral influences on end-of-life decisions.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Palliative Care, Version 2.2019 - February 8, 2019. In: Editor (ed)^(eds) Book NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Palliative Care, Version 2.2019 - February 8, 2019, City
The Quality Oncology Practice Initiative (QOPI) Reporting Registry. In: Editor (ed)^(eds) Book The Quality Oncology Practice Initiative (QOPI) Reporting Registry, City
Earle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, Ayanian JZ (2008) Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J Clin Oncol 26:3860–3866
Earle CC, Neville BA, Landrum MB, Souza JM, Weeks JC, Block SD, Grunfeld E, Ayanian JZ (2005) Evaluating claims-based indicators of the intensity of end-of-life cancer care. Int J Qual Health Care 17:505–509
Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S (2003) Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 21:1133–1138
Goodman DC FE, Chang C, Morden NE, Jacobson JO, Murray K, Miesfeldt S (2010) Quality of end-of-life cancer care for Medicare beneficiaries The Dartmouth Institute for Health Policy and Clinical Practice
Wallston KA, Burger C, Smith RA, Baugher RJ (1988) Comparing the quality of death for hospice and non-hospice cancer patients. Med Care 26:177–182
Wright AA, Keating NL, Ayanian JZ, Chrischilles EA, Kahn KL, Ritchie CS, Weeks JC, Earle CC, Landrum MB (2016) Family perspectives on aggressive cancer care near the end of life. JAMA 315:284–292
Guadagnolo BA, Liao KP, Giordano SH, Elting LS, Shih YC (2015) Variation in intensity and costs of care by payer and race for patients dying of cancer in Texas: an analysis of registry-linked Medicaid, medicare, and dually eligible claims. Data Med Care 53:591–598
Koroukian SM, Schiltz NK, Warner DF, Given CW, Schluchter M, Owusu C, Berger NA (2017) Social determinants, multimorbidity, and patterns of end-of-life care in older adults dying from cancer. J Geriatr Oncol 8:117–124
Ramey SJ, Chin SH (2012) Disparity in hospice utilization by African American patients with cancer. Am J Hosp Palliat Care 29:346–354
Virnig BA, Kind S, McBean M, Fisher E (2000) Geographic variation in hospice use prior to death. J Am Geriatr Soc 48:1117–1125
Virnig BA, Morgan RO, Persily NA, DeVito CA (1999) Racial and income differences in use of the hospice benefit between the medicare managed care and medicare fee-for-service. J Palliat Med 2:23–31
Jarosek SL, Shippee TP, Virnig BA (2016) Place of death of individuals with terminal cancer: new insights from Medicare hospice place-of-service codes. J Am Geriatr Soc 64:1815–1822
McCarthy EP, Burns RB, Ngo-Metzger Q, Davis RB, Phillips RS (2003) Hospice use among Medicare managed care and fee-for-service patients dying with cancer. JAMA 289:2238–2245
Smith AK, Earle CC, McCarthy EP (2009) Racial and ethnic differences in end-of-life care in fee-for-service Medicare beneficiaries with advanced cancer. J Am Geriatr Soc 57:153–158
Stevenson DG, Ayanian JZ, Zaslavsky AM, Newhouse JP, Landon BE (2013) Service use at the end-of-life in Medicare advantage versus traditional Medicare. Med Care 51:931–937
Virnig BA, Fisher ES, McBean AM, Kind S (2001) Hospice use in Medicare managed care and fee-for-service systems. Am J Manag Care 7:777–786
Virnig BA, Persily NA, Morgan RO, DeVito CA (1999) Do Medicare HMOs and Medicare FFS differ in their use of the Medicare hospice benefit? Hosp J 14:1–12
Emanuel EJ, Ash A, Yu W, Gazelle G, Levinsky NG, Saynina O, McClellan M, Moskowitz M (2002) Managed care, hospice use, site of death, and medical expenditures in the last year of life. Arch Intern Med 162:1722–1728
Morrison RS MD (1995) Managed Care At The end of life trends in health care, law & ethics 10: 91-96
Keating NL, Herrinton LJ, Zaslavsky AM, Liu L, Ayanian JZ (2006) Variations in hospice use among cancer patients. J Natl Cancer Inst 98:1053–1059
Barbera L, Seow H, Sutradhar R, Chu A, Burge F, Fassbender K, McGrail K, Lawson B, Liu Y, Pataky R, Potapov A (2015) Quality indicators of end-of-life care in patients with cancer: what rate is right? J Oncol Pract 11:e279–e287
De Schreye R, Smets T, Annemans L, Deliens L, Gielen B, De Gendt C, Cohen J (2017) Applying quality indicators for administrative databases to evaluate end-of-life care for cancer patients in Belgium. Health Aff (Millwood) 36:1234–1243
Smith CEP, Kamal AH, Kluger M, Coke P, Kelley MJ (2019) National trends in end-of-life care for veterans with advanced cancer in the Veterans Health Administration: 2009 to 2016. J Oncol Pract:JOP1800559
Funding
Supported by a grant from the Cancer Prevention and Research Institute of Texas, “CERCIT: Comparative Effectiveness Research on Cancer in Texas” RP160674
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
This research was supported by a grant from the Cancer Prevention Research Institute of Texas (RP160674). The funding source was uninvolved in the conduct of the research and the interpretation of results. The authors declare no conflicts of interest with the funder and none with other entities related to the research. The authors have full control of the data which were obtained under a Data Use Agreement from the Texas Cancer Registry and the Centers for Medicare and Medicaid Services. These data are confidential and cannot be shared.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Elting, L.S., Liao, KP., Giordano, S.H. et al. Hospice enrollment among cancer patients in Texas covered by Medicare managed care and traditional fee-for-service plans: a statewide population-based study. Support Care Cancer 28, 3351–3359 (2020). https://doi.org/10.1007/s00520-019-05142-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00520-019-05142-z