Medicare Advantage Enrollees Less Satisfied with End-of-Life Care

Families of Medicare Advantage enrollees report being less satisfied with the end-of-life care their loved ones received than those covered by traditional Medicare. Stakeholders have called for careful quality monitoring as the Medicare Advantage hospice carve-in approaches.

Families of Medicare Advantage beneficiaries were more likely to say that care was “less than excellent,” and indicated that they found communication regarding the patients’ conditions was lacking, according to a recent study published in the Journal of the American Medical Association. This trend held firm regardless of whether the beneficiary receive hospice care. 

“In this cross-sectional study of people who died while enrolled in Medicare, friends and family of those in MA reported lower-quality end-of-life care compared with friends and family of those enrolled in traditional Medicare,” the researchers reported. “These findings suggest that, given the rapid growth of MA, Medicare should take steps to ensure that MA plans are held accountable for quality of care at the end of life.”


The cross-sectional research used the 2011 to 2017 Medicare-linked National Health and Aging Trends Study to conduct population-based survey research. Of the 2,119 individuals in the research sample, 670 were enrolled in Medicare Advantage at the time of death or prior to hospice, and 1,449 were enrolled in traditional Medicare. 

The difference in family satisfaction was particularly pronounced among patients in nursing homes. For the nursing home population, more than 57% enrolled in traditional Medicare reported less-than-excellent care compared with 77.9% for patients in Medicare Advantage.

Medicare Advantage plans will have the option to cover hospice care for the first time beginning in 2021 through the demonstration project to test hospice coverage through the value-based insurance design model (VBID), or the carve-in.


Among Medicare Advantage plans, 53 will be covering hospice in 2021 through the VBID model, according to CMS. The carve-in comes at a time when Medicare Advantage is seeing record-high levels of participation for 2021 among beneficiaries, reaching about 42% for 2021, CMS reported.

Currently, when a Medicare Advantage beneficiary enters hospice, their coverage transitions out of the MA program to the Medicare Hospice Benefit. While the MA plan may continue to cover the patient, it would only apply to care or services that are unrelated to the terminal diagnosis.

The impact of the carve-in on patient and family satisfaction remains to be seen. One of the goals of the program is to create more seamless transitions of care for patients entering hospice; this alone may cause satisfaction to improve.

The demonstration project will also hold Medicare Advantage plans to a number of quality metrics, which could also drive improvement, according to the study’s authors.

“As part of the demonstration, MA plans will be held accountable for the quality of end-of-life care, which presents an opportunity for quality improvement. Our results suggest that it is critical that Medicare conduct mortality follow-back surveys that directly capture the experience of the bereaved,” the authors wrote. “Through appropriate quality measurement, reporting, and payment incentives, MA plans could be incentivized to limit the care delivered by health care facilities (including nursing facilities) and clinicians that provide low-quality care at the end of life and to implement supports to improve quality of care, such as through geriatric and palliative care teams.”