Hospice use among Medicare managed care and fee-for-service patients dying with cancer

JAMA. 2003 May 7;289(17):2238-45. doi: 10.1001/jama.289.17.2238.


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 coverage areas.

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.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Fee-for-Service Plans / statistics & numerical data*
  • Hospice Care / statistics & numerical data*
  • Humans
  • Length of Stay
  • Managed Care Programs / statistics & numerical data*
  • Medicare / statistics & numerical data*
  • Neoplasms / mortality*
  • Proportional Hazards Models
  • Retrospective Studies
  • SEER Program
  • Terminally Ill / statistics & numerical data*
  • United States / epidemiology