A COMPARISON BY PAYOR PROVIDER TYPE OF THE COST OF DYING AMONG FRAIL OLDER ADULTS/

OEJECTIVE: 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-mo nth intervals for an 18-month period. Utilization and cost data were c ollected directly from providers and the Health Care Financing Adminis tration for 12 months immediately before death for decedents and for t he first 12 months of follow-up for survivors. SAMPLE: Five hundred se venty-seven frail older patients of an integrated healthcare system wh o were receiving physician prescribed home health services, under Medi care fee-for-service (FFS), Medicare HMO, or Medicare-Medicaid coverag e. Frailty was defined as the receipt of physician-prescribed home hea lthcare services. OUTCOME MEASURES: Acute and long-term healthcare ser vice utilization and expenditures; total healthcare expenditures. RESU LTS: After controlling for baseline differences, significant differenc es in utilization and expenditures of survivors (n = 450) and decedent s (n = 127) were demonstrated. Compared with survivors, frail older de cedents were approximately: 7 times as likely to have had any hospital admissions 3 times as likely to have had one or more emergency room v isits 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 f or survivors. Total expenditures for Medicaid-Medicare beneficiaries w ere 42% higher than expenditures for FFS participants, primarily becau se of higher hospitalization and emergency room expenditures. There we re no differences in utilization and expenditures between HMO enrollee s 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 peopl e exhibit the same pattern of higher expenditures and service utilizat ion as the general Medicare population. However, differences between d ecedents' and survivors' healthcare expenditures and resource use did not vary by payor/provider. Thus, cost-containment strategies should f ocus on new forms of managing healthcare services beyond those current ly practiced within Medicare HMOs, traditional FFS, or Medicare-Medica id in California.