0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Contribution |

Influence of Age on Medicare Expenditures and Medical Care in the Last Year of Life FREE

Norman G. Levinsky, MD; Wei Yu, PhD; Arlene Ash, PhD; Mark Moskowitz, MD; Gail Gazelle, MD; Olga Saynina, MA, MBA; Ezekiel J. Emanuel, MD, PhD
[+] Author Affiliations

Author Affiliations: Health Care Research Unit, Section of General Internal Medicine (Drs Ash and Moskowitz), Department of Medicine (Drs Levinsky, Ash, and Moskowitz), Boston University School of Medicine, Boston, Mass; Health Economics Resource Center of Health Services Research and Development Services and Center for Cooperative Studies in Health Services, US Department of Veterans Affairs, Menlo Park, Calif (Dr Yu); Palliative and Supportive Medicine Program, Harvard Vanguard Medical Associates, Boston, Mass (Dr Gazelle); National Bureau of Economic Research, Palo Alto, Calif (Ms Saynina); and Department of Clinical Bioethics, National Institutes of Health, Bethesda, Md (Dr Emanuel).


JAMA. 2001;286(11):1349-1355. doi:10.1001/jama.286.11.1349.
Text Size: A A A
Published online

Context Expenditures for Medicare beneficiaries in the last year of life decrease with increasing age. The cause of this phenomenon is uncertain.

Objectives To examine this pattern in detail and evaluate whether decreases in aggressiveness of medical care explain the phenomenon.

Design, Setting, and Patients Analysis of sample Medicare data for beneficiaries aged 65 years or older from Massachusetts (n = 34 131) and California (n = 19 064) who died in 1996.

Main Outcome Measure Medical expenditures during the last year of life, analyzed by age group, sex, race, place and cause of death, comorbidity, and use of hospital services.

Results For Massachusetts and California, respectively, Medicare expenditures per beneficiary were $35 300 and $27 800 among those aged 65 through 74 years vs $22 000 and $21 600 for those aged 85 years or older. The pattern of decreasing Medicare expenditures with age is pervasive, persisting throughout the last year of life in both states for both sexes, for black and white beneficiaries, for persons with varying levels of comorbidity, and for those receiving hospice vs conventional care, regardless of cause and site of death. The aggressiveness of medical care in both Massachusetts and California also decreased with age, as judged by less frequent hospital and intensive care unit admissions and by markedly decreasing use of cardiac catheterization, dialysis, ventilators, and pulmonary artery monitors, regardless of cause of death. Decrease in the cost of hospital services accounts for approximately 80% of the decrease in Medicare expenditures with age in both states.

Conclusions Medicare expenditures in the last year of life decrease with age, especially for those aged 85 years or older. This is in large part because the aggressiveness of medical care in the last year of life decreases with increasing age.

Figures in this Article

There is great interest in the cost of medical care in the last year of life. Expenditures for Medicare beneficiaries who die each year are approximately 5 times as high per person as for survivors.1 However, Medicare expenditures for Medicare beneficiaries in the last year of life decrease as age increases; this pattern has been found in studies of data from 1976,1 1978,2 1988,1 and 1992.3 To understand this phenomenon, we examined the pattern of expenditures with age in more detail, stratifying 1996 Medicare data by sex, race, comorbidity, use of hospice care, place and cause of death, and type of health care services used. In addition, we have examined changes in the aggressiveness of medical care with age, as judged by the frequency of admissions to a hospital and to care in an intensive care unit (ICU), and by the use of aggressive interventions such as ventilators, pulmonary artery monitors, cardiac catheterization, and dialysis.

Sample Selection

We used data from 2 states, Massachusetts and California, rather than national data, because this made it feasible to obtain information about place and cause of death, key variables for our analysis. In both states, we selected Medicare beneficiaries who died in 1996, were enrolled in the Medicare program throughout their last year of life, and were not enrolled in Medicare's End Stage Renal Disease program. To obtain an adequate sample size for each state, the study sample consisted of all decedents in Massachusetts and a randomly selected 20% of decedents from the much larger state of California.

We used the denominator file from the Health Care Financing Administration to merge with each state's 1996 death certificate files. In Massachusetts, 42 452 decedents met the above conditions. In merging with the Massachusetts death certificate file, we used social security number, date of birth, date of death, and sex. A match was accepted if either of the following 2 conditions was met: (1) perfect match in social security number and either sex or both date of birth and date of death; or (2) a match on 7 of the 9 positions in the social security number and a perfect match in each of the sex, date of birth, and date of death categories. This left 39 447 people (93%). To fully characterize a person's health care use through the Medicare files, both Part A (hospital insurance) and Part B (supplementary medical insurance) entitlement are required. Thus, we retained only the 37 933 beneficiaries who were continuously entitled to both kinds of insurance throughout their last 12 months of life.

In California, we used the same method to merge the Medicare denominator file to the death certificate file. The 20% sample contained 33 684 decedents. Among the 33 684 people, 96% were linked to the death certificate file. After merging with the death certificate file and excluding people who did not meet the conditions listed above, we retained 27 658 decedents. Finally, since Health Care Financing Administration files do not contain complete information about health care use for beneficiaries enrolled in managed care plans, we limited our study to people enrolled in the standard fee-for-service Medicare program during each of the last 12 months of life. This resulted in a study population of 34 131 decedents in Massachusetts and 19 064 in California.

Expenditure Data

The total insurance expenditure was calculated as the sum of Health Care Financing Administration payments. When a beneficiary's primary health insurance was not covered by Medicare, payments were calculated by what Medicare would have paid. The average payment per person from other insurance plans accounts for only 0.15% of the total expenditure. Out-of-pocket expenses and Medigap copayments and deductibles are not included. Expenditure for each person was calculated from the following files: Medicare Provider Analysis and Review, including acute hospitalizations, long-term hospitalizations, and skilled nursing home care, hospital outpatient, part B physician/supplier, home health care, and hospice.

Analysis

We analyzed expenditures during the last year of life by age, sex, race, and place and cause of death. We used the National Center for Health Statistics4 classification to group decedents by cause of death. Information from the death certificate file was used to group place of death. We examined differences in expenditures between people who used any hospice and those who did not. We also examined the influence of comorbidity on expenditures, using the Charlson score5 to estimate comorbidity. Persons were grouped into 3 levels of comorbidity: Charlson scores 0 to 2; 3 to 4; and 5 or more. In addition, we determined expenditures for each type of health care service, such as for hospitals or physicians. Hospital expenditures are for acute care hospitalizations only. Physician expenditures include insurance payments for all types of physician services covered by the Medicare Part B insurance plan.

Hospital Services

We estimated the aggressiveness of medical care in the last year of life from 2 types of indices, hospitalization and selected aggressive services. Using the Medicare Provider Analysis and Review records, we identified admissions that included care in an ICU, which we defined as including coronary care units but excluding psychiatric ICUs. We also examined use patterns during the last year of life for ventilators and pulmonary artery monitors, usually used in an ICU; and for cardiac catheterization and dialysis, which are not limited to ICUs. These treatments were identified from the surgical procedure codes (up to 10) reported in the Medicare Provider Analysis and Review file.

Statistical Significance

All statistical analyses used SAS statistical software, version 6.11 (SAS Institute Inc, Cary, NC). Differences in expenditures (costs) or other outcomes across the 3 age categories (65-74, 75-84 and ≥85 years) were tested using analyses of variance. The Duncan test was used for pairwise differences between age groups. The coefficient of variation (the mean divided by the SD), associated with costs in these data is typically less than 1.3. Thus, when comparing costs for 2 groups with at least 500 persons each, differences of just under 10% are statistically significant at the P = .05 level. In fact, most comparisons of costs across age groups involve several thousand people in each group and show differences larger than 10%. Thus, virtually all pairwise comparisons are statistically significant, even at the P<.001 level. For simplicity of presentation, given the many tests performed, we note in the tables only the absence of a statistically significant difference between the oldest and youngest subgroups at the P = .05 level.

In addition, we used the SAS GLM procedure (SAS Institute Inc) to perform a global test for a decrease in cost with age in California and Massachusetts. In each state, we regressed cost on sex, race (black and white vs other), cause of death (heart disease, stroke, cancer, chronic obstructive pulmonary disease, pneumonia vs other), Charlson comorbidity score, and age. A trend of decreasing cost with age is supported when the coefficient of age in the regression is both statistically significant and negative. Suppose, for example, that the coefficient of age is −$500. Then, among people whose sex, race, cause of death, and comorbidity burden was the same, we would expect 80 year olds to cost $5000 less than those who are aged 70 years.

As shown in Table 1, Medicare expenditures during the last year of life decrease with age. For all beneficiaries, the decrease between the ages of 75 to 84 years and 85 years or older is about twice as great as that between the ages of 65 through 74 years and 75 through 84 years. The decrease with age is noted in both men and women. The pattern of decreasing expenditures with age was of approximately similar magnitude in both whites and blacks. (Expenditures in each age category were higher for blacks than for whites. We are studying this observation in a database with a larger number of blacks.) Medicare expenditures decreased with age both in persons who used hospice services and those who did not. Medicare expenditures increased with increasing levels of comorbidity, as measured by the Charlson score.5 At each level of comorbidity, expenditures decreased with age.

Table Graphic Jump LocationTable 1. Medicare Expenditures During the Last Year of Life, by Sex, Race, Hospice Care, and Comorbidity*

We performed a global test (see Methods) to evaluate the regression of expenditures (cost) on age, which held sex, race, cause of death, and comorbidity score constant. Each additional year of age was associated with a $413 decrease in cost in Massachusetts and a $408 decrease in California. Each of these effects was significant at the P<.001 level.

The age trends were similar in the 2 states and persisted throughout the year prior to death. Figure 1 shows the data by month from Massachusetts; data from California were similar. The decrease with age was noted in every 30-day period in both states.

Figure. Medicare Expenditures for Beneficiaries in Massachusetts During the Last Year of Life
Graphic Jump Location

As shown in Table 2, the pattern of decreasing expenditure during the last year of life with age was noted for all causes of death. The trends of the data by age and diagnosis were quite comparable in Massachusetts and California. The data also were analyzed to determine whether the site of death influenced the pattern of expenditures (Table 3). In both states, expenditures in the last year of life were highest for those who died in an inpatient setting, lower for those who died in a nursing home, and lowest for those who died in a residence. The pattern of decreasing expenditures with increasing age was comparable for persons dying in each of these sites.

Table Graphic Jump LocationTable 2. Medicare Expenditures During the Last Year of Life, by Cause of Death*
Table Graphic Jump LocationTable 3. Medicare Expenditures During the Last Year of Life, by Place of Death*

As shown in Table 4, expenditures for hospital inpatient care accounted for more than half of total expenditures. Expenditures for hospital care decreased by about half between the ages of 65 through 74 years and 85 years or older. The decrease in hospital expenditures between the ages of 65 through 74 years and 85 years or older accounted for most of the overall age-related decrease in expenditures: 79.6% in Massachusetts and 81.9% in California. Expenditures for outpatient care and physician services also decreased with age. On the contrary, expenditures for care in skilled nursing facilities and to a lesser extent for home health services increased with age. The trends in the 2 states were comparable.

Table Graphic Jump LocationTable 4. Medicare Expenditures During the Last Year of Life, by Type of Service*

As shown in Table 5, admissions in the last year of life, which were about 10% lower in California than in Massachusetts, decreased progressively among the 3 age groups in both states. Admissions were about 30% lower in those aged 85 years or older than in those aged 65 through 74 years. The number of admissions to ICUs decreased with age. It was more than 50% lower in those aged 85 years or older than in those aged 65 through 74 years. The percentage of admissions that included some care in an ICU also decreased with age, declining by about 40% in Massachusetts and 25% in California between the youngest and oldest age groups. The frequency of use of the other indices of aggressive services also decreased with age. The decrease was especially striking for the oldest group (aged ≥85 years). For that group, the use of ventilators and pulmonary artery monitors was reduced by about two thirds. Cardiac catheterization was 85% less frequent. Dialysis (outside the End Stage Renal Disease program, which we did not study) was 88% less frequent in Massachusetts and 75% less frequent in California. The decrease in use of the aggressive procedures was indicated by 2 types of data. There was a decrease in the number of all procedures per 1000 persons with age. There also was a decrease with age in the percentage of admissions that included some care in an ICU and those in which cardiac catheterization or dialysis were used. The percentage of ICU admissions in which a ventilator or pulmonary artery monitor was used also decreased with age.

Table Graphic Jump LocationTable 5. Hospital Services During the Last Year of Life*

We also evaluated the pattern of use of hospital services separately for each of the 5 most frequent causes of death, which account for 75% of deaths in Massachusetts and 80% in California (Table 6). The pattern of decreasing hospital and ICU admissions, especially for the oldest groups, was found for each major cause of death. The pattern of decreasing use of aggressive services with age also was generally noted for all causes except cancer. Although the use of monitors, catheterization, and dialysis decreased numerically between the youngest and the oldest groups in cancer patients, the differences were not statistically significant.

Table Graphic Jump LocationTable 6. Hospital Services During the Last Year of Life, by Cause of Death*

We found that the pattern of decreasing expenditures with increasing age for medical care of the elderly in their last year of life, especially for the "oldest old" (aged 85 years or older), is pervasive. It is present for both sexes, for both black and white beneficiaries, for those in hospice as well as those in conventional care, regardless of the degree of comorbidity and the cause or the place of death. The decrease in expenditures with age in the last year of life is in large part the result of less aggressive care with increasing age. Several observations buttress this conclusion. First, 80% of the decrease in total expenditures with age is accounted for by the decrease in expenditures for hospital services. Second, the 50% decrease in cost for hospitalization of beneficiaries in their last year of life is much greater than the 30% decrease in the number of hospitalizations with increasing age, suggesting reduced intensity of care of the older groups during hospitalization. Finally, the various indices of aggressiveness that we evaluated confirm this conclusion. The percentage of hospital admissions that included care in an ICU decreased with age, as did the frequency of use of ventilators and pulmonary artery monitors, even in persons admitted to an ICU. The use of cardiac catheterization and dialysis (in persons not in the End Stage Renal Disease program) also decreased with age, especially for the group aged 85 years or older. Age appears to be a key determinant in decisions about medical care for older persons.

We examined the influence of the cause of death, which presumably reflects the major illness during the last year of life, on the pattern of age-related expenditures and on the use of the hospital services that served as indices of aggressive care. Expenditures decreased with increasing age for each of the most frequent causes. Riley et al,6 using 1979 data, made comparable observations. Thus, the pattern of decreasing expenditures with increasing age cannot be explained by differential costs for different causes of death. Decreasing use of aggressive care with age also was noted for each of the most frequent causes of death. It appears that both the decreased frequency of hospital admissions and the reduced use of aggressive therapy account for most of the decrease in expenditures with age.

These observations are compatible with other reports that indicate decreased intensity of care for older Medicare beneficiaries in their last year of life, especially those in the oldest group. Using 1992 data from a national Medicare population, Levinsky et al3 found that major surgical procedures decreased with age; Yu et al7 found decreasing use of the ICU. Also consistent with this conclusion are some observations from the SUPPORT study810 (Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments), which evaluated the care of seriously ill patients at 5 medical centers. The age range of the patients was wider than in the present study; the median age was 65 years. The SUPPORT investigators found that older age was associated with higher rates of decisions to withhold aggressive care, after adjusting for prognosis, patient preferences, severity of illness, and prior functional status. Johnson and Kramer11 studied physicians' responses to clinical scenarios involving life-threatening illness. At all levels of probability of survival, a significant proportion of physicians favored treating a younger patient more aggressively than an older patient with the same likelihood of survival. From these various studies, it appears that older patients at the end of their natural lifespan are treated much less aggressively than younger patients. This is contrary to the opinions of some policy analysts and ethicists12,13 who suggest that such persons are subjected to unreasonably aggressive and expensive medical care.

There are several limitations to the generalizability of our results. Our data are derived from Massachusetts and California. Although data from the 2 states are comparable, it is possible they do not accurately reflect national data. Against the likelihood of major differences, however, is the fact that trends of expenditures and hospital and ICU admissions with age are comparable with those reported in studies with national Medicare data.3,7 Our data also do not include persons in managed care programs, since Medicare files do not contain complete information about health care use for beneficiaries enrolled in a managed care program. Medicare files also exclude individuals who received their medical care from the Veterans Affairs medical program.

The pattern of decreasing expenditure with age may represent appropriate clinical decisions by patients, their families, and their physicians to curtail unreasonably aggressive care in older patients who are unlikely to benefit from such care. The cognitive and functional status of individuals and potential gains in functional life must be considered in deciding whether to use interventions that may cause pain or discomfort. Moreover, life is not necessarily shortened if aggressive care is withheld. In the SUPPORT study, the decrease in survival with age was not due to decreased aggressiveness of care with increasing age.10,14 Alternatively, the decrease in intensity of care with age may represent age discrimination in the use of medical care.11 The SUPPORT study concluded that many older patients prefer aggressive therapy, a preference that often is not appreciated by their physicians or family.10,14 Analysis of the clinical care of individuals will be required to separate these possibilities.

Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life.  N Engl J Med.1993;328:1092-1096.
Lubitz J, Prihoda R. The use and costs of Medicare services in the last 2 years of life.  Health Care Financ Rev.1984;5:117-131.
Levinsky NG, Ash AS, Yu W, Moskowitz MA. Patterns of use of common major procedures in medical care of older adults.  J Am Geriatr Soc.1999;47:553-558.
Pickle LW, Mungiole M, Jones GK, White AA. Atlas of United States MortalityHyattsville, Md: US Dept of Health and Human Services, Centers for Disease Control and Prevention; 1996:4.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic co-morbidity in longitudinal studies: development and validation.  J Chronic Dis.1987;40:373-383.
Riley G, Lubitz J, Prihoda R, Rabey E. The use and costs of Medicare services by cause of death.  Inquiry.1987;24:233-244.
Yu W, Ash AS, Levinsky NG, Moskowitz MA. Intensive care unit use and mortality in the elderly.  J Gen Intern Med.2000;15:97-102.
Hamel MB, Teno JM, Goldman L.  et al.  Patient age and decisions to withhold life-sustaining treatments from seriously ill, hospitalized adults.  Ann Intern Med.1999;130:116-125.
Hamel MB, Phillips RS, Teno JM.  et al.  Seriously ill hospitalized adults: do we spend less on older patients?  J Am Geriatr Soc.1996;44:1043-1048.
Hamel MB, Lynn J, Teno JM.  et al.  Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT.  J Am Geriatr Soc.2000;48:S176-S182.
Johnson MF, Kramer AM. Physicians' responses to clinical scenarios involving life-threatening illness vary by patients' age.  J Clin Ethics.2000;11:323-327.
Callahan D. Death and the research imperative.  N Engl J Med.2000;342:654-656.
Fries JF. Aging, natural death, and the compression of morbidity.  N Engl J Med.1980;303:130-135.
Hamel MB, Davis RB, Teno JM.  et al.  Older age, aggressiveness of care, and survival for seriously ill, hospitalized adults.  Ann Intern Med.1999;131:721-728.

Figures

Figure. Medicare Expenditures for Beneficiaries in Massachusetts During the Last Year of Life
Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Medicare Expenditures During the Last Year of Life, by Sex, Race, Hospice Care, and Comorbidity*
Table Graphic Jump LocationTable 2. Medicare Expenditures During the Last Year of Life, by Cause of Death*
Table Graphic Jump LocationTable 3. Medicare Expenditures During the Last Year of Life, by Place of Death*
Table Graphic Jump LocationTable 4. Medicare Expenditures During the Last Year of Life, by Type of Service*
Table Graphic Jump LocationTable 5. Hospital Services During the Last Year of Life*
Table Graphic Jump LocationTable 6. Hospital Services During the Last Year of Life, by Cause of Death*

References

Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life.  N Engl J Med.1993;328:1092-1096.
Lubitz J, Prihoda R. The use and costs of Medicare services in the last 2 years of life.  Health Care Financ Rev.1984;5:117-131.
Levinsky NG, Ash AS, Yu W, Moskowitz MA. Patterns of use of common major procedures in medical care of older adults.  J Am Geriatr Soc.1999;47:553-558.
Pickle LW, Mungiole M, Jones GK, White AA. Atlas of United States MortalityHyattsville, Md: US Dept of Health and Human Services, Centers for Disease Control and Prevention; 1996:4.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic co-morbidity in longitudinal studies: development and validation.  J Chronic Dis.1987;40:373-383.
Riley G, Lubitz J, Prihoda R, Rabey E. The use and costs of Medicare services by cause of death.  Inquiry.1987;24:233-244.
Yu W, Ash AS, Levinsky NG, Moskowitz MA. Intensive care unit use and mortality in the elderly.  J Gen Intern Med.2000;15:97-102.
Hamel MB, Teno JM, Goldman L.  et al.  Patient age and decisions to withhold life-sustaining treatments from seriously ill, hospitalized adults.  Ann Intern Med.1999;130:116-125.
Hamel MB, Phillips RS, Teno JM.  et al.  Seriously ill hospitalized adults: do we spend less on older patients?  J Am Geriatr Soc.1996;44:1043-1048.
Hamel MB, Lynn J, Teno JM.  et al.  Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT.  J Am Geriatr Soc.2000;48:S176-S182.
Johnson MF, Kramer AM. Physicians' responses to clinical scenarios involving life-threatening illness vary by patients' age.  J Clin Ethics.2000;11:323-327.
Callahan D. Death and the research imperative.  N Engl J Med.2000;342:654-656.
Fries JF. Aging, natural death, and the compression of morbidity.  N Engl J Med.1980;303:130-135.
Hamel MB, Davis RB, Teno JM.  et al.  Older age, aggressiveness of care, and survival for seriously ill, hospitalized adults.  Ann Intern Med.1999;131:721-728.
CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 106

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
JAMAevidence.com

Care at the Close of Life EDUCATION GUIDES
Practical Considerations in Dialysis Withdrawal


Hemodialysis