@article {7752, title = {Out-of-pocket spending in the last five years of life.}, journal = {J Gen Intern Med}, volume = {28}, year = {2013}, month = {2013 Feb}, pages = {304-9}, publisher = {28}, abstract = {

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{\textquoteright} 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{\textquoteright}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{\textquoteright} expenditures exceeded baseline total household assets, and 43 \% of subjects{\textquoteright} 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{\textquoteright}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.

}, keywords = {Aged, Cause of Death, Female, Health Expenditures, Health Services for the Aged, Humans, Male, Marital Status, Medicare, Retrospective Studies, Socioeconomic factors, Terminal Care, United States}, issn = {1525-1497}, doi = {10.1007/s11606-012-2199-x}, author = {Amy Kelley and Kathleen McGarry and Sean Fahle and Samuel M Marshall and Qingling Du and Jonathan S Skinner} }