# Medicare Advantage and End of Life Care for Patients with Advanced Dementia

> **NIH NIH R03** · UNIVERSITY OF IOWA · 2020 · $74,358

## Abstract

Even though a growing number of Americans are dying with dementia, several receive
suboptimal care near the end of life. Reported problems include under-diagnosis and poor
treatment of pain, painful and unnecessary investigations and inappropriate use of aggressive
treatments. Some studies have reported that capitated Medicare-Advantage (MA) plans, that
are paid on a per-person (rather than a per-service) basis, may be better positioned than
traditional fee-for-service Medicare to promote the use of recommended services at the end of
life while discouraging unnecessary hospitalizations and invasive procedures. In addition, the
hospice “carve-out” also creates a strong financial incentive for MA plans to promote hospice
enrollment among their terminally ill patients. On the other hand, capitated payments incentivize
MA plans to selectively contract with health providers and restrict services and choice of
providers in order to control costs. MA beneficiaries face higher cost-sharing if they receive care
from providers outside of their network. Narrow networks can also influence quality of care
directly if higher-quality providers are unwilling to accept low payment rates. Therefore, the
relationship between MA enrollment on service use and quality of care is potentially a mixture of
different effects that vary across outcomes and patients, necessitating robust empirical evidence
on both the direction and magnitude of these effects. Much of existing literature in this area
focuses on the use of a few health services, does not account for potential selection bias in MA
enrollment, precedes enrollment changes accompanying the 2010 health reform, and does not
specifically focus on dementia patients. Our study employs multiple waves of unique population-
based mortality follow-back data associated with the Health and Retirement Study (HRS) (2000-
2014) and the National Health and Aging Trends Study (NHATS) (2012-2017) to examine the
relationship between MA enrollment and three categories of end of life care outcomes: patterns
of care (including site of death), out-of-pocket expenditures and perceived quality of end of life
care, among dementia decedents. It also harnesses the core HRS and NHATS files to account
for longitudinal patterns of insurance coverage among dementia decedents. We also propose
several sensitivity and heterogeneity analyses to enhance the robustness of our findings.

## Key facts

- **NIH application ID:** 10056604
- **Project number:** 1R03AG067284-01A1
- **Recipient organization:** UNIVERSITY OF IOWA
- **Principal Investigator:** Kanika Arora
- **Activity code:** R03 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $74,358
- **Award type:** 1
- **Project period:** 2020-08-15 → 2022-04-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10056604

## Citation

> US National Institutes of Health, RePORTER application 10056604, Medicare Advantage and End of Life Care for Patients with Advanced Dementia (1R03AG067284-01A1). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10056604. Licensed CC0.

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