As Medicare turns 50, researchers writing in the Journal of the American Medical Association examine changes in major outcomes over the last 15 years. (JAMA Article) The researchers looked at all-cause mortality rates, hospitalization rates, overall costs and costs in the last month, 3 months and 6 months of life for the period 1999 to 2013. Over this time Medicare Advantage enrollees have risen from 17.9% to 29% of beneficiaries and dual eligibles constituted 11.9% of people in MA by 2013. Overall, the average age of beneficiaries was unchanged, there were more African-Americans as a percent and the percent of women declined as more men lived long enough to be and stay in the program. For fee-for-service beneficiaries, rates of heart failure, heart attack, stroke and cancer declined, while rates of diabetes and asthma increased.
Due to data limitations in regard to the MA program, most of the outcomes were only measured for the fee-for-service enrollees, but recent research suggests that any difference in the illness burden between MA and fee-for-service beneficiaries has largely disappeared. All-cause mortality across the program declined from 5.3% in 1999 to 4.45% in 2013. In the fee-for-service population, the decline was the same across age, sex, race and geographic location. Dual-eligibles showed higher rates of mortality throughout the study period. In the fee-for-service group, hospitalization rates declined from 35,274 per 100,000 beneficiaries in 1999 to 26,390 in 2013, and the number of unique patients admitted at least once similarly declined. Major surgical procedures on an inpatient basis decreased as well. There was geographic variability in hospitalization related rates.
In-hospital mortality and 30-day post admission mortality declined significantly. Median length-of-stay decreased from 5 to 4 days over the study period. Mores discharges went went to intermediate care or skilled nursing facilities, home with care, hospice or long-term care by 2013 compared to 1999. The average annual inflation-adjusted spending on hospitalization per beneficiary declined from $3290 to $2801. And for all the concern about end-of-life spending, the utilization of inpatient care declined dramatically in the last 6 months of life, and the average length of stay declined as well. The overall average expenditures in these last 6 months rose in the early part of the study period but declined from 2009 to 2013. The last month of life continued to be particularly expensive, accounting for 60% of all spending in the last 6 months of life. So big picture, for the Medicare program, beneficiaries appear to be dying less, using hospital less and costing less.