Wednesday, April 25, 2007
Medical expenditures during the last year of life: findings from the 1992-1996 Medicare Current Beneficiary Survey - Cost of Care
The elderly (65 years of age and older) have consumed more than 33 percent of health care spending (Waldo, Sonnefeld, and Arnett 1989). Their medical expenses are substantially higher in the last year of life (Scitovsky 1984; Riley et al. 1987; Scitovsky 1988; Gaumer and Stavins 1992; Temkin-Greener et al. 1992; Lubitz and Riley 1993; Scitovsky 1994; Barnato et al. 1999). While only 5 percent of elderly Medicare beneficiaries have died annually, the percentage of elderly Medicare expenditures spent on persons in the last year of life fluctuates between 27 percent and 31 percent (Lubitz and Riley 1993; Hogan et al. 2001). Mean annual Medicare expenditures for the last 12 months of life in the elderly rose from $1,924 in 1976 to about $23,000 in 1995, but the pardon of Medicare expenditures spent on beneficiaries in the last year of life did not change during this time period (Lubitz and Riley 1993; Garber, MaCurdy, and McClellan 1999; Hogan et al 2001).
Inpatient hospital expenditures constitute a large portion of end-of-life expenses, but use of this service by terminally ill patients declined in the late 1980s and early 1990s (Temkin-Greener et al. 1992; Lubitz and Riley 1993; Scitovsky 1994; Garber MaCurdy, and McClellan 1999). Still, Garber et al. (1999) observed that hospital inpatient Medicare expenditures in the last year of life among the 20 percent Medicare sample grew from 1989-1995, although perhaps not as rapidly as did expenditures for other services during this time period. Recent initiatives to promote the use of home health care, hospice, and advanced directives might be expected to curtail "unnecessary" or unwanted inpatient hospital and other end-of-life services, but these services are difficult to target without also reducing valuable services (Emanuel and Emanuel 1994).
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The continuing growth of population in the oldest age groups in the United States could also change the portion of medical expenditures spent on the last year of life either through larger numbers of elderly deaths or different medical spending patterns for those dying at the oldest ages. Medicare expenditures during the last 12 months of life decline with age at death (McCall 1984; Scitovsky 1984; Lubitz and Riley 1993). Reasons suggested for this include shorter intervals between illness and death and decreased use of acute care, hospitals, and other services with older age at death (Gaumer and Stavins 1992; Scitovsky 1994), as well as less desire among the oldest individuals or their health care providers to use advanced (and expensive) technological methods to prolong their lives (Kramer 1995). By contrast, endof-life non-Medicare expenses are higher among those with older age at death. Three studies observed rising non-Medicare expenditures with older age at death during the last 90 days of life (Temkin- Greener et al. 1992), last year of life (Scitovsky 1984), and last two years of life (Spillman and Lubitz 2000). This increase in terminal year non-Medicare expenditures with older age at death was largely from greater long-term care facility expenditures for older decedents.
Evaluating Medicare and non-Medicare expenditures among the elderly near the end of life remains important as the American population ages. But end-of-life non-Medicare and total elderly medical expenditures have not been studied or compared to non-end-of-life expenditures in a national sample. We, therefore, study 1992-1996 Medicare and non-Medicare expenditures during the last 12 months of life (referred to as "terminal year expenditures") as compared to expenditures before the last 12 months of life (referred to as "nonterminal year expenditures") using data from the Medicare Beneficiary Survey (MCBS). Expenses are subdivided according to service, payer, and person's age. Implications of the findings with respect to current and future health care costs and efforts to reduce medical expenditures are discussed.
METHODS
Study Population and Expenditure Data
The 1992-1996 MOBS is a weighted, stratified, multistage, area probability sample of Medicare enrollees (community and facility dwellers) drawn from the Medicare enrollment file maintained by the Health Care Financing Administration (HCFA). This sample is supplemented annually to add newly enrolled individuals and replace attrition from death. The MCBS interviews participants/proxies every four months, reviewing all health care encounters with the assistance of calendars, along with explanation of benefits from all payers. To improve accuracy of data, respondents record medical events/ procedures on special calendars, and bring receipts, statements, and medication containers to the interview. In computing Medicare expenditures, MCBS cross-checks and supplements the survey with Medicare claims information. For facility residents, billing office workers are asked to provide data on charges and payments. However, only total health care expenditures for a calendar year (or the portion of the year a person survive s) are recorded and non-Medicare costs cannot be subdivided further from available information on dates of service. More details on the MCBS are given elsewhere (Olin, Liu, and Merriman 1996; Eppig and Chulis 1997). This analysis includes full-year Medicare enrollees aged 65 and older on January 1 of the MCBS calendar year.
Inpatient hospital expenditures constitute a large portion of end-of-life expenses, but use of this service by terminally ill patients declined in the late 1980s and early 1990s (Temkin-Greener et al. 1992; Lubitz and Riley 1993; Scitovsky 1994; Garber MaCurdy, and McClellan 1999). Still, Garber et al. (1999) observed that hospital inpatient Medicare expenditures in the last year of life among the 20 percent Medicare sample grew from 1989-1995, although perhaps not as rapidly as did expenditures for other services during this time period. Recent initiatives to promote the use of home health care, hospice, and advanced directives might be expected to curtail "unnecessary" or unwanted inpatient hospital and other end-of-life services, but these services are difficult to target without also reducing valuable services (Emanuel and Emanuel 1994).
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The continuing growth of population in the oldest age groups in the United States could also change the portion of medical expenditures spent on the last year of life either through larger numbers of elderly deaths or different medical spending patterns for those dying at the oldest ages. Medicare expenditures during the last 12 months of life decline with age at death (McCall 1984; Scitovsky 1984; Lubitz and Riley 1993). Reasons suggested for this include shorter intervals between illness and death and decreased use of acute care, hospitals, and other services with older age at death (Gaumer and Stavins 1992; Scitovsky 1994), as well as less desire among the oldest individuals or their health care providers to use advanced (and expensive) technological methods to prolong their lives (Kramer 1995). By contrast, endof-life non-Medicare expenses are higher among those with older age at death. Three studies observed rising non-Medicare expenditures with older age at death during the last 90 days of life (Temkin- Greener et al. 1992), last year of life (Scitovsky 1984), and last two years of life (Spillman and Lubitz 2000). This increase in terminal year non-Medicare expenditures with older age at death was largely from greater long-term care facility expenditures for older decedents.
Evaluating Medicare and non-Medicare expenditures among the elderly near the end of life remains important as the American population ages. But end-of-life non-Medicare and total elderly medical expenditures have not been studied or compared to non-end-of-life expenditures in a national sample. We, therefore, study 1992-1996 Medicare and non-Medicare expenditures during the last 12 months of life (referred to as "terminal year expenditures") as compared to expenditures before the last 12 months of life (referred to as "nonterminal year expenditures") using data from the Medicare Beneficiary Survey (MCBS). Expenses are subdivided according to service, payer, and person's age. Implications of the findings with respect to current and future health care costs and efforts to reduce medical expenditures are discussed.
METHODS
Study Population and Expenditure Data
The 1992-1996 MOBS is a weighted, stratified, multistage, area probability sample of Medicare enrollees (community and facility dwellers) drawn from the Medicare enrollment file maintained by the Health Care Financing Administration (HCFA). This sample is supplemented annually to add newly enrolled individuals and replace attrition from death. The MCBS interviews participants/proxies every four months, reviewing all health care encounters with the assistance of calendars, along with explanation of benefits from all payers. To improve accuracy of data, respondents record medical events/ procedures on special calendars, and bring receipts, statements, and medication containers to the interview. In computing Medicare expenditures, MCBS cross-checks and supplements the survey with Medicare claims information. For facility residents, billing office workers are asked to provide data on charges and payments. However, only total health care expenditures for a calendar year (or the portion of the year a person survive s) are recorded and non-Medicare costs cannot be subdivided further from available information on dates of service. More details on the MCBS are given elsewhere (Olin, Liu, and Merriman 1996; Eppig and Chulis 1997). This analysis includes full-year Medicare enrollees aged 65 and older on January 1 of the MCBS calendar year.
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