If you’ve heard our AgingOptions radio program, read our blog or attended a LifePlanning Seminar, this statement should sound familiar: one of the things seniors fear most is being forced late in life into institutional care against their wishes. We would add a corollary to that statement to say that, given a choice, older people would much rather die at home, in familiar surroundings with family nearby, than in an acute care hospital in the company of strangers.

Outcomes Differ Between Medicare, Medicare Advantage

A few weeks ago we discovered this article on the Forbes magazine website with a blunt title: “Where Do Older Americans Die?” We think this brief article is important reading for anyone engaged in retirement planning, since thinking ahead to the end of your life is something you need to do in advance, not in the midst of a health crisis. The good news in the Forbes analysis is that the number of seniors spending their last days in the hospital is declining significantly while the number who die at home is on the rise. But there’s an interesting twist to the statistics. It appears that seniors insured by traditional Medicare are actually more likely to face a hospital death than those covered by Medicare Advantage plans. We’ll consider two possible reasons why in a moment.

“Increasingly, older Americans are likely to die at home, and not in a hospital,” the Forbes article reports. “However, stubbornly large numbers of Medicare beneficiaries still land in intensive care units or find themselves shuttled from home to hospital and back again in their last months of life.” This is the conclusion from a new report published in the Journal of the American Medical Association which reviewed 15 years’ worth of data, examining the outcomes for thousands of seniors who died with medical insurance through traditional Medicare. Researchers then compared these outcomes against an equally large number of people covered by the newer Medicare Advantage plans. “Both the overall percentages and the trends,” Forbes says, “tell important stories to consider as we think of how we want to live in our last months.”

Passing Away at Home

First, as the article reports, let’s consider the good news. In 2000, the first year of the study data, about one-third of Medicare enrollees passed away in an acute care hospital. Fifteen years later that percentage had dropped to about 20 percent. At the same time, Forbes says, the percentage of those dying at home (including assisted living) increased from about 30 percent in 2000 to 40 percent in 2015. For Medicare Advantage policy-holders, the likelihood of spending your last days in your own home was even higher – roughly fifty percent. On the surface this seems encouraging, as it appears to reflect a desire on the part of health care professionals to honor the wishes of older patients who are close to the end of life.

But there’s more to the story, as the article explains. “Even though seniors were less likely to die in a hospital,” says Forbes, “it doesn’t mean they were not being admitted to hospitals and spending time in intensive care units as they neared end of life.” Among traditional Medicare patients, the JAMA study said that more than half of study subjects spent time in the hospital during the last 30 days of their lives. Two-thirds were hospitalized in the last 90 days. Both these percentages were higher (by about ten percentage points) for Medicare patients than for Medicare Advantage policy holders. The MA patients were also significantly less likely to spend all or part of their final month in a nursing home, the experience of roughly one-third of seniors, compared with 43 percent for those on regular Medicare. (Those on Medicare are also more likely to experience “potentially burdensome care” in which they are moved in and out of multiple care sites or face multiple hospitalizations in their final few months.)

What Accounts for the Difference?

So why is there this discrepancy? Why do so many more seniors on Medicare end their days in the hospital, in a nursing home, or in ICU than those covered by Medicare Advantage plans? The Forbes article hints at two possible answers. “Critics of MA plans,” says the report, “would probably say that their enrollees were not hospitalized because the plans were reluctant to spend money on patients who were close to death or, worse, those patients died because they did not get the medical care they needed.” This is the negative spin on the data. But considering the fact that most seniors prefer to avoid hospitalization at the end of their lives, there’s another explanation. “There is growing evidence that intense treatment at the end of life…harms patients and their families, and often is contrary to the wishes of many older adults. In that case,” says Forbes, “the financial incentives in managed care that discourage use of hospital or nursing home stays at the end of life may be well aligned with the needs and wishes of patients.” If this theory is true, MA plans may actually turn out to be unexpectedly more responsive than Medicare to the end-of-life desires of patients and their families.

How We Want to Live

As we said earlier, these types of discussions about dying – as difficult as they can be – are an important part of planning for your future. Does your family know your end-of-life wishes? Have you placed your health care in the hands of a geriatrician who is trained to respond to the needs of senior patients? These kinds of family and health issues are just part of a process we call LifePlanning, a comprehensive approach to retirement planning in which health and family matters are woven together with financial, legal and housing plans to create a seamless LifePlan, a blueprint that will help you create the kind of retirement you’ve always wanted. Knowing how you want to die may be important, but it’s far more important to know how you want to live. A LifePlan is the best tool we know of to help you experience true retirement freedom and security.

There’s a simple and highly informative way to find out more about this breakthrough in retirement planning. Please accept our invitation to join Rajiv Nagaich at a free LifePlanning Seminar. All the upcoming seminar locations, dates and times are listed here on our Live Events page. Once you’ve made your selection, reserve your place by registering online, or by calling us during the week. It will be our pleasure to meet you at a LifePlanning Seminar soon!

(originally reported at www.forbes.com)