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Managed Care, Hospice Use, Site of Death, and Medical Expenditures in the Last Year of Life
Ezekiel J. Emanuel, MD, PhD;
Arlene Ash, PhD;
Wei Yu, PhD;
Gail Gazelle, MD;
Norman G. Levinsky, MD;
Olga Saynina, MBA;
Mark McClellan, MD, PhD;
Mark Moskowitz, MD
Arch Intern Med. 2002;162:1722-1728.
Background We examined deaths of Medicare beneficiaries in Massachusetts and California
to evaluate the effect of managed care on the use of hospice and site of death
and to determine how hospice affects the expenditures for the last year of
life.
Methods Medicare data for beneficiaries in Massachusetts (n = 37 933) and
California (n = 27 685) who died in 1996 were merged with each state's
death certificate files to determine site and cause of death. Expenditure
data were Health Care Financing Administration payments and were divided into
30-day periods from the date of death back 12 months.
Results In Massachusetts, only 7% of decedents were enrolled in managed care
organizations (MCOs); in California, 28%. More than 60% of hospice users had
cancer. Hospice use was much lower in Massachusetts than in California (12%
vs 18%). In both states, decedents enrolled in MCOs used hospice care much
more than those enrolled in fee-for-service plans (17% vs 11% in Massachusetts
and 25% vs 15% in California). This pattern persisted for those with cancer
and younger (aged 65-74 years) decedents. Decedents receiving hospice care
were significantly (P<.001 for both) less likely
to die in the hospital (11% vs 43% in Massachusetts and 5% vs 43% in California).
Enrollment in MCOs did not affect the proportion of in-hospital deaths (those
enrolled in fee-for-service plans vs MCOs: 40% vs 39% in Massachusetts; and
37% vs 34% in California). Expenditures in the last year of life were $28 588
in Massachusetts and $27 814 in California; about one third of the expenditures
occurred in the last month before death. Hospital services accounted for more
than 50% of all expenditures in both states, despite 77% of decedents being
hospitalized in Massachusetts and just 55% being hospitalized in California.
Among patients with cancer, expenditures were 13% to 20% lower for those in
hospice.
Conclusions Medicare-insured decedents in California were more than 4 times more
likely to be enrolled in MCOs, were 50% more likely to use a hospice, and
had a 30% lower hospitalization rate than decedents in Massachusetts, yet
there are few differences in out-of-hospital deaths or expenditures in the
last year of life. However, patients with cancer using hospice did have significant
savings.
From the Department of Clinical Bioethics, Warren G. Magnuson Clinical
Center, National Institutes of Health, Bethesda, Md (Dr Emanuel); the Health
Care Research Unit, Section of General Internal Medicine (Drs Ash, Yu, and
Moskowitz), and the Department of Medicine (Drs Ash, Levinsky, and Moskowitz),
Boston University School of Medicine, Boston, Mass; the Palliative and Supportive
Medicine Program, Harvard Vanguard Medical Associates, Boston (Dr Gazelle);
and the National Bureau of Economic Research, Palo Alto, Calif (Ms Saynina
and Dr McClellan). Dr Yu is now with Health Services Research and Development
Field Program and the Cooperative Studies Program, US Department of Veterans
Affairs and Center for Health Policy and Center for Primary Care and Outcomes
Research, Stanford University, Stanford, Calif.
Dr Moskowitz died September
1, 2001.
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