Racial and Ethnic Differences in End‐of‐Life Medicare Expenditures

Abstract

Objectives To determine to what extent racial and ethnic variation in Medicare spending during the last six months of life are explained by demographic, social support, socioeconomic, geographic, medical and EOL planning factors. Design Retrospective cohort study Setting Health and Retirement Study (HRS) Participants 7,105 decedents who participated in the Health and Retirement Study between 1998–2012 and previously consented to survey linkage with Medicare claims. Measurements Total Medicare expenditures in the last 180 days of life by race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected. Results Our analysis included 5548 (78.1%) non-Hispanic white, 1030 (14.5%) non-Hispanic black, 331 (4.7%) Hispanic, and 196 (2.8%) adults of other race/ethnicity. Unadjusted results suggest that average Medicare expenditures for black decedents was $13,522 (35%, p <0.001) more than for whites, while Medicare expenditures for Hispanics was $16,341 (42%, p<0.001) more at EOL. Controlling for demographic, socioeconomic, geographic, medical and EOL specific factors, the Medicare expenditure difference between groups reduced to $8,047 (22%, p<0.001) more for black and $6,855 (19%, p<0.001) more for Hispanic decedents compared to non-Hispanic whites’ expenditures. The expenditure differences between groups remained statistically significant across all models. Conclusion Racial and ethnic differences in Medicare spending in the last six months of life are not fully explained by patient-level factors, including EOL planning factors. Future research should focus on broader systemic, organizational and provider level factors to explain these differences.

Racial Disparities in Hospice Outcomes: A Race or Hospice‐Level Effect?

“…Blacks receive more intensive and higher-cost treatments at the end of life, including greater rates of hospital admissions, emergency department (ED) visits, intensive care unit (ICU) stays, gastrostomies for artificial nutrition, mechanical ventilation, and cardiopulmonary resuscitation. [1][2][3][4][5][6] Consistent with this pattern, blacks are less likely to enroll in hospice than nonminorities, despite the growth of hospice across the country during the past decade. [7][8][9] For example, using 2014 data, an estimated 76% of all hospice enrollees were white; only 7.6% were black.…”

“…Multiple studies have found disparities between blacks and whites in intensity of care at the end of life. Blacks receive more intensive and higher‐cost treatments at the end of life, including greater rates of hospital admissions, emergency department (ED) visits, intensive care unit (ICU) stays, gastrostomies for artificial nutrition, mechanical ventilation, and cardiopulmonary resuscitation . Consistent with this pattern, blacks are less likely to enroll in hospice than nonminorities, despite the growth of hospice across the country during the past decade .…”

Modes of Death Within a Children’s Hospital

“…Data from adults who are at the end of life reveal that African American patients are less likely to complete advance directives 31 or enroll in hospice 32 and are more likely to receive aggressive end-of-life care in the hospital. 33,34 Researchers have suggested that although this may be partially due to a difference in preferences, 35 -37 personal health values cannot be used to fully explain the differences. 31, 38 Authors of previous studies have highlighted the racial differences in palliative care referrals, 8 DNR status, 6 and location of death in children 39 but have not offered explanations as to why these differences exist.…”

Potentially burdensome end‐of‐life transitions among nursing home residents with poor‐prognosis cancer

“…At the resident level, we found that burdensome EOL transitions were more common in nonwhites and those with multiple comorbidities. Racial disparities in EOL care are well described . Although the association between functional impairment and health care utilization is a well‐described phenomenon in community dwellers with and without cancer and in NH residents with curable cancers, we found that coexisting functional impairment and advanced cancer were associated with increased odds of burdensome EOL transitions.…”

“…Racial disparities in EOL care are well described. [34][35][36][37] Although the association between functional impairment and health care utilization is a well-described phenomenon in community dwellers with and without cancer 38,39 and in NH residents with curable cancers, 40 we found that coexisting functional impairment and advanced cancer were associated with increased odds of burdensome EOL transitions. NH residents with functional impairment and advanced cancer may have complex symptoms and care needs that are challenging to manage.…”