How Would Hospice Use Differ if Every Medicare Beneficiary Were in Medicare Advantage?

Background: Hospice use is higher in the growing Medicare Advantage (MA) program compared to Traditional Medicare (TM). It is uncertain if this is due to different hospice referral patterns. Objectives: To compare hospice use patterns in MA versus TM across beneficiary characteristics. Design: Retrospective cohort study. Setting/Subjects: United States decedents in the Medicare Current Beneficiary Survey (2010–2022). Measurements: We employed a counterfactual modeling approach: among those in MA, we estimated the association between hospice use and sociodemographic, health, and regional characteristics. We then applied these coefficients to the TM population to predict hospice use had they been enrolled in MA. Results: Among 5153 decedents, 35.3% were in MA at death. Compared to TM decedents, MA decedents were younger, more likely to be Hispanic, less likely to reside in a facility, and less likely to report serious illnesses (dementia, cancer, stroke, heart disease, and lung disease). We estimated that if TM decedents had been enrolled in MA, hospice use would have been 6.1% higher (95% confidence interval, CI, 3.4%−8.8%) versus observed hospice use in TM. This difference was pronounced among those with higher education and serious illnesses in TM: for example, 10.1% higher for those with dementia (95% CI 6.9%−13.3%) versus without dementia (2.5% higher, 95% CI 1.2% lower–6.1% higher). Conclusions: Relative to TM, hospice use is highest among MA beneficiaries with higher education and specific serious illnesses. Future work needs to assess the drivers of this difference (e.g., palliative care, networks).