Medicare plan switching, hospice enrollment, and place of hospice services at the end-of-life among decedent patients diagnosed with distant stage cancers in 2010-2019.
Authors: Xin Hu, Changchuan Jiang, Youngmin Kwon, Qinjin Fan, Kewei Sylvia Shi, Zhiyuan Zheng, Jingxuan Zhao, Joan L. Warren, Robin Yabroff, Xuesong Han
Journal: Journal of Clinical Oncology (2025)

11089 Background: Prior studies showed higher hospice utilization among Medicare Advantages (MA) than among Traditional Medicare (TM) beneficiaries. With more beneficiaries enrolling in MA and switching between TM and MA in recent years, this study examines hospice utilization patterns and associated factors among patients with advanced cancers enrolled in continuous TM, continuous MA, or switching between these plans. Methods: We identified Medicare beneficiaries aged ≥66 years diagnosed with distant-stage breast, colorectal, lung, pancreatic, or prostate cancers in 2010-2019 and followed through 2020 from SEER-Medicare data. Patients surviving ≥3 months post-diagnosis were categorized by plan-switching patterns: continuous TM, continuous MA, switching from TM-to-MA, and from MA-to-TM. Outcomes included hospice enrollment in the last year of life, within 14 days of death, and site of last hospice service (e.g., home, nursing home, hospice facility, inpatient facility, or other). Multivariable regression models estimated associations of plan-switching patterns and patient characteristics with study outcomes. Results: Among a total of 196,568 patients with advanced cancers, plan switching was relatively infrequent, with 1.5% switching from TM-to-MA and 1.8% from MA-to-TM. Beneficiaries who switched plans were more likely to be racial or ethnic minorities and dual-eligible than those with continuous coverage. Hospice enrollment in the last year of life was highest for continuous MA (74.8%), followed by TM-to-MA (69.0%), continuous TM (68.5%), and MA-to-TM (66.4%). Enrollment within 14 days of death was similar across groups. The last hospice service was received at home by 49% of beneficiaries, followed by 7.6% at hospice facilities, 6.7% at nursing homes, and 5.3% at inpatient facility. Compared to continuous TM, continuous MA and TM-to-MA switching beneficiaries had higher likelihoods of receiving last hospice service at home (6.2 ppts and 3.0 ppts respectively, p-values&lt;.01), while MA-to-TM beneficiaries had higher likelihoods of receiving last hospice service at nursing homes (1.7 ppts, p&lt;.001). Beneficiaries who gained dual eligibility had increased likelihood of receiving last hospice service at nursing homes (25.8 ppts, p&lt;.001) and decreased likelihood of receiving last hospice service at home (-23.5 ppts, p&lt;.001) than non-dual-eligible beneficiaries. Conclusions: Continuous MA coverage was associated with greater likelihood of hospice utilization, particularly at home. In contrast, switching from MA-to-TM and gaining dual eligibility were associated with greater reliance on nursing homes for hospice care. Future research examining patient-centered outcomes across plan-switching patterns and addressing care coordination gaps to ensure equitable hospice care are warranted.