Differences in Medicare expenditures during the last 3 years of life

Abstract

Objective: To examine age, gender, race, and area income differences in Medicare expenditures in the 3 years before death.

Design: Cross-sectional study.

Participants: A random sample of aged Medicare beneficiaries who died 1996 to 1999, N = 241,047.

Measures: We estimate differences in mean Medicare expenditures by year before death and by age, gender, race, and area income, adjusting for comorbidities and Medicaid enrollment.

Results: Expenditures for blacks are lower in the second and third years before death and are not significantly different from whites in the last year of life (LYOL) (y3 = 70%, P <.0001; y2 = 82%, P <.0001; LYOL = 119%, P =.098). Differences in expenditures between decedents with area incomes over $35,000 compared to under $20,000 attenuate by the LYOL (y3 = 116%, P <.0001; y2 = 107%, P <.0001; LYOL = 96%, P <.0001). Expenditure patterns for women versus men vary by age. Among the younger cohorts (68 to 74 and 75 to 79), expenditures are higher for women in all 3 years before death. This difference attenuates among older cohorts; in the oldest cohort (90+), expenditures for men exceed those for women by 11% in the LYOL (P <.0001). Older beneficiaries have higher expenditures in the second and third years before death but lower expenditures in the LYOL. On average, the youngest cohort expended $8,017 more in the LYOL relative to the oldest cohort, whereas in the third year before death, the oldest cohort's expenditures were $5,270 more than those for the youngest cohort (P <.0001).

Conclusions: Age-associated differences in aggregate Medicare payments for end-of-life care are more substantial than other differences. The fact that other differences attenuate in the LYOL may reflect having overcome barriers to health care, or reflect an effective ceiling on the opportunities to provide services for persons with overwhelming illness.

FIGURE 1

Ratio of regression-adjusted mean Medicare spending, in the last 3 years of life, by age at death. ^*†* Reference group for all ratios is the 68 to 74 age cohort. Regression-adjusted means were calculated for each beneficiary characteristic, controlling for other characteristics. Ratios were calculated by dividing mean expenditures for older cohorts by mean expenditures for the 68 to 74 age cohort. The bar in the figure is set at 1.0, reflecting no difference in expenditures. ^† Ninety-five percent of confidence intervals presented for each ratio.

FIGURE 2

Ratio of regression-adjusted mean Medicare expenditures for women as compared to men in the last 3 years of life, by age at death. ^*†* Regression-adjusted means were calculated for each beneficiary characteristic, controlling for other characteristics. Ratios calculated by dividing mean expenditures for women by mean expenditures for men within each age cohort. The bar in the figure is set at a ratio of 1.0, reflecting no difference in expenditures. ^† Ratios are statistically significant at P < .01, with the exception of the ratio of expenditures for the 85 to 89 age cohort, in the last year of life (95% confidence internal [CI] 1.00 to 1.11).

FIGURE 3

Ratio of regression-adjusted mean Medicare expenditures for blacks as compared to whites in the last 3 years of life, by age at death. ^*†* Regression-adjusted means were calculated for each beneficiary characteristic, controlling for other characteristics. Ratios calculated by dividing mean expenditures for blacks by mean expenditures for whites within each age cohort. The bar in the figure is set at a ratio of 1.0, reflecting no difference in expenditures. ^† Ratios for blacks versus whites are statistically significant at P < .01, with the exception of the ratio for those age 68 to 74 in the last year of life (95% CI, 0.94 to 1.01), age 75 to 79 in the last year of life (95% CI, 1.00 to 1.14), age 85 to 89 in the second year before death (95% CI, 0.77 to 1.00), age 90+ in the second year before death (95% CI, 0.86 to 1.11), and age 90+ in the third year before death (95% CI, 0.75 to 1.09).