Differences in Medicare Service Use in the Last Six Months of Life Among Rural and Urban Dual – Eligible Beneficiaries


Overall, rural dual-eligible decedents may experience some modest disparities during the last six months of life when compared to urban dual-eligible beneficiaries. The principal potential rural disparity was Medicare-funded hospice use, which was lower among rural than urban beneficiaries even among decedents with Alzheimer's disease. Lower hospice use found in this study parallels similar findings among Medicare beneficiaries with cancer, among whom hospice use was less common for rural residents. It is unlikely that Medicaid hospice benefits are replacing Medicare benefits for this service, as only a small proportion of hospice patients are funded by Medicaid. Rural communities as a whole are less likely to have a hospice within 30 or 60 minutes travel time, which could affect both awareness of and use of the service. Looking only within rural beneficiaries and comparing Medicare only and dual-eligible cohorts, dual-eligible rural beneficiaries were less likely to have experienced an inpatient stay, ambulance transport, home health, or hospice services. Findings with regard to outpatient care were mixed, with physician visits being less common among dual-eligible than Medicare only beneficiaries, while outpatient clinic visits more common among dual eligible individuals. When the analysis was restricted to decedents who had a diagnosis of Alzheimer's disease, use of both types of outpatient care was higher among dual-eligible than Medicare only beneficiaries. Because of low numbers of observations for Hispanic decedents and persons of other race/ethnicity, only white and African American beneficiaries are compared. Within persons with Medicare only insurance, there were no differences based on race in the use of any services except home health, which was more commonly used among African American than white decedents. Among dual-eligible individuals, African American beneficiaries were more likely to have used physician, inpatient, ambulance and home health services, and less likely to have used hospice, than their white peers. Absent data on beneficiary preferences, and lacking information regarding services that may have been paid by Medicaid, it is difficult to confirm rural disparities in utilization of Medicare funded services among dual-eligible beneficiaries for any service except Medicare hospice. Additional research is recommended to link facility use with facility availability, to ensure that differences between populations result from choice rather than from availability.

Rural and Minority Health Research Center
Elizabeth Crouch, Kevin Bennett, Janice Probst