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Weeks WB, Cao SY, Lester CM, Weinstein JN. Association of Declines in End-of-Life Health Care Costs With Fee-for-Service Enrollee Per Capita Expenditures. JAMA Netw Open. 2020;3(3):e200861. doi:10.1001/jamanetworkopen.2020.0861
A dominant health policy narrative is that end-of-life (EOL) spending is a key driver of health care cost growth.1 Recent studies suggest that EOL care intensity is rising2 and that increased spending on hospice care costs more than it saves,3 raising concerns that per capita expenditures on EOL care might further accelerate.
Nonetheless, between 2000 and 2014, annual fee-for-service (FFS) Medicare spending growth was lower for decedents than for survivors,4 and real reductions in per capita Medicare FFS expenditures attributed to decedents accounted for most of Medicare’s cost growth mitigation between 2009 and 2014.5 We sought to determine whether that pattern has continued.
In this cross-sectional study, between October 1 and December 1, 2019, we examined Medicare FFS beneficiaries who were continuously enrolled in Parts A and B for at least 2 consecutive years (or until death in the second year) between 2011 and 2017. We calculated decedents’ Part A and B expenditures for the 365 days before death and removed them from the prior year’s survivor cohort, for which we calculated Part A and B expenditures for the calendar year. We attributed decedents’ expenditures in their final year of life to the year of their death.
We calculated annual consumer price index–adjusted per capita expenditures overall and in 6 categories: inpatient (hospital or skilled nursing facility), physician, outpatient hospital, home health, hospice, and durable medical equipment. As described elsewhere,5 we attributed those expenditures to survivors and decedents for each year from 2012 through 2017.
For survivors and decedents, we examined absolute and relative changes in overall and category-specific attributed per capita expenditure annual growth rates for all FFS Medicare beneficiaries, for those enrolled in an accountable care organization (ACO; limited to 2013 through 2017), for dual-eligible beneficiaries, and for those living in the least and most economically distressed communities (as determined by zip code–level Distressed Communities Index scores, described elsewhere6).
This work was conducted following Solutions Institutional Review Board approval as non–human subject research, with Centers for Medicare and Medicaid approval. The report follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
A total of 41 252 443 Medicare FFS beneficiaries were included in this study from 2012 to 2017, with 8 424 016 decedents (4 527 894 women [54%]; mean [SD] age, 78  years) and 32 828 427 survivors (18 105 323 women [55%]; mean [SD] age, 67  years). Year-over-year growth rates in attributed per capita outpatient hospital care expenditures were positive for decedents and survivors throughout the period examined (among decedents, growth rates of 1.8% in 2012-2013, 2.5% in 2013-2014, 5.9% in 2014-2015, 1.2% in 2015-2016, and 4.2% in 2016-2017; among survivors, growth rates of 2.0% in 2012-2013, 5.2% in 2013-2014, 4.7% in 2014-2015, 2.8% in 2015-2016, and 3.9% in 2016-2017) (Table 1). Aside from home health and hospice care, decedents’ attributed per capita expenditure growth generally was lower than survivors’ (for example, year-over-year growth rates for decedents’ physician care were 1.6% lower than survivors’ in 2012-2013, 3.2% lower in 2013-2014, 1.3% lower in 2014-2015, 3.9% lower in 2015-2016, and 0.5% lower in 2016-2017). Invariably, attributable per capita cost growth was lower for decedents than for survivors (decedents’ total per capita cost growth rates were 0.9% lower than survivors’ in 2012-2013, 2.8% lower in 2013-2014, 0.4% lower in 2014-2015, 2.4% lower in 2015-2016, and 0.7% lower in 2016-2017).
Between 2012 and 2017, decedents’ relative spending reductions were greatest among those enrolled in ACOs (total relative change in spending was 18% lower for decedents than for survivors) and least among the dually eligible (total relative change in spending was 3% lower for decedents than for survivors) (Table 2). Beneficiaries dying in the most economically distressed communities had greater relative spending reductions than did those dying in the least distressed communities (total relative changes in spending, −16% vs −10%).
Between 2012 and 2017, year-over-year overall and service-specific growth rates in inflation-adjusted Medicare FFS per capita expenditures attributable to decedents and survivors were generally negative, except in 2014 to 2015. Growth rates for home health and hospice services were higher among decedents than survivors; otherwise, growth generally was lower for decedents than for survivors. Among defined cohorts, decedents who had been enrolled in an ACO or who died in more economically distressed communities had the greatest relative spending declines, but all cohorts experienced relative increases in decedents’ attributable per capita hospice care expenditures.
Although this study is limited by its focus on the 2012 to 2017 FFS Medicare population, its findings suggest that EOL care is not a driver but rather a mitigator of Medicare FFS cost growth, seemingly because EOL care patterns continue to shift to less intensive, more conservative care strategies. Although we could not adjust for demographic or health differences in our defined cohorts, main outcomes were robust across all of them. More study is required to understand the reasons for that shift, whether relative reductions in EOL expenditures influence care quality, and why relative changes in per capita expenditures on decedents varied so dramatically across the cohorts we examined.
Accepted for Publication: January 8, 2020.
Published: March 17, 2020. doi:10.1001/jamanetworkopen.2020.0861
Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2020 Weeks WB et al. JAMA Network Open.
Corresponding Author: William B. Weeks, MD, PhD, MBA, Microsoft, 14820 NE 36th St, Redmond, WA 98052 (firstname.lastname@example.org).
Author Contributions: Dr Lester and Ms Cao had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Weeks, Weinstein.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Weeks, Weinstein.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Cao, Weinstein.
Obtained funding: Lester, Weinstein.
Administrative, technical, or material support: Cao, Lester.
Supervision: Weeks, Lester, Weinstein.
Conflict of Interest Disclosures: None reported.
Disclaimer: The findings expressed in this article are solely those of the authors and not necessarily those of the Economic Innovation Group. The Economic Innovation Group does not guarantee the reliability of, or necessarily agree with, the information provided herein.
Additional Information: This article used proprietary data provided by the Economic Innovation Group.
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