B. Experton et al., A COMPARISON BY PAYOR PROVIDER TYPE OF THE COST OF DYING AMONG FRAIL OLDER ADULTS/, Journal of the American Geriatrics Society, 44(9), 1996, pp. 1098-1107
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.