Out-of-pocket spending in the last five years of life.

TitleOut-of-pocket spending in the last five years of life.
Publication TypeJournal Article
Year of Publication2013
AuthorsKelley, A, McGarry, K, Fahle, S, Marshall, SM, Du, Q, Skinner, JS
JournalJ Gen Intern Med
Date Published2013 Feb
ISSN Number1525-1497
KeywordsAged, Cause of Death, Female, Health Expenditures, Health Services for the Aged, Humans, Male, Marital Status, Medicare, Retrospective Studies, Socioeconomic factors, Terminal Care, United States

BACKGROUND: A key objective of the Medicare program is to reduce risk of financial catastrophe due to out-of-pocket healthcare expenditures. Yet little is known about cumulative financial risks arising from out-of-pocket healthcare expenditures faced by older adults, particularly near the end of life.

DESIGN: Using the nationally representative Health and Retirement Study (HRS) cohort, we conducted retrospective analyses of Medicare beneficiaries' total out-of-pocket healthcare expenditures over the last 5 years of life.

PARTICIPANTS: We identified HRS decedents between 2002 and 2008; defined a 5 year study period using each subject's date of death; and excluded those without Medicare coverage at the beginning of this period (n = 3,209).

MAIN MEASURES: We examined total out-of-pocket healthcare expenditures in the last 5 years of life and expenditures as a percentage of baseline household assets. We then stratified results by marital status and cause of death. All measurements were adjusted for inflation to 2008 US dollars.

RESULTS: Average out-of-pocket expenditures in the 5 years prior to death were $38,688 (95 % Confidence Interval $36,868, $40,508) for individuals, and $51,030 (95 % CI $47,649, $54,412) for couples in which one spouse dies. Spending was highly skewed, with the median and 90th percentile equal to $22,885 and $89,106, respectively, for individuals, and $39,759 and $94,823, respectively, for couples. Overall, 25 % of subjects' expenditures exceeded baseline total household assets, and 43 % of subjects' spending surpassed their non-housing assets. Among those survived by a spouse, 10 % exceeded total baseline assets and 24 % exceeded non-housing assets. By cause of death, average spending ranged from $31,069 for gastrointestinal disease to $66,155 for Alzheimer's disease.

CONCLUSION: Despite Medicare coverage, elderly households face considerable financial risk from out-of-pocket healthcare expenses at the end of life. Disease-related differences in this risk complicate efforts to anticipate or plan for health-related expenditures in the last 5 years of life.

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Endnote Keywords

Public policy/Medicare/End of life/health expenditures/out of pocket costs

Endnote ID


Alternate JournalJ Gen Intern Med
Citation Key7752
PubMed ID22948931
PubMed Central IDPMC3614143
Grant ListP30 AG028741 / AG / NIA NIH HHS / United States
1P30AG28741-01 / AG / NIA NIH HHS / United States
K23 AG040774 / AG / NIA NIH HHS / United States
U01 AG009740 / AG / NIA NIH HHS / United States
R24 HD041022 / HD / NICHD NIH HHS / United States
T32 AG033533 / AG / NIA NIH HHS / United States
P01 AG019783 / AG / NIA NIH HHS / United States
P01-AG19783 / AG / NIA NIH HHS / United States
1 T32-AG033533 / AG / NIA NIH HHS / United States