A comparison by payor/provider type of the cost of dying among frail older adults.

OBJECTIVE: To compare expenditures and healthcare service use between decedents (in their last year of life) and survivors, all of whom were frail older people, under three payor/provider types.

DESIGN: In-home interviews were conducted by home care nurses at baseline and at 6-month intervals for an 18-month period. Utilization and cost data were collected directly from providers and the Health Care Financing Administration for 12 months immediately before death for decedents and for the first 12 months of follow-up for survivors.

SAMPLE: Five hundred seventy-seven frail older patients of an integrated healthcare system who were receiving physician prescribed home health services, under Medicare fee-for-service (FFS), Medicare HMO, or Medicare-Medicaid coverage. Frailty was defined as the receipt of physician-prescribed home healthcare services.

OUTCOME MEASURES: Acute and long-term healthcare service utilization and expenditures; total healthcare expenditures.

RESULTS: After controlling for baseline differences, significant differences in utilization and expenditures of survivors (n = 450) and decedents (n = 127) were demonstrated. Compared with survivors, frail older decedents were approximately: 7 times as likely to have had any hospital admissions 3 times as likely to have had one or more emergency room visits 8 times as likely to have 30 or more physician visits 4 times as likely to have been admitted to a skilled nursing facility and twice as likely to have used home health services after the baseline episode. On average, total expenditures for decedents were 276% higher than for survivors. Total expenditures for Medicaid-Medicare beneficiaries were 42% higher than expenditures for FFS participants, primarily because of higher hospitalization and emergency room expenditures. There were no differences in utilization and expenditures between HMO enrollees and FFS beneficiaries. Finally, interactions between decedent status and payor/provider were not statistically significant in multivariate analyses.

CONCLUSION: During the last year of life, frail older people exhibit the same pattern of higher expenditures and service utilization as the general Medicare population. However, differences between decedents' and survivors' healthcare expenditures and resource use did not vary by payor/provider. Thus, cost-containment strategies should focus on new forms of managing healthcare services beyond those currently practiced within Medicare HMOs, traditional FFS, or Medicare-Medicaid in California.