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Four Paths to the End of Life -- One far More Expensive Than Others -- Emerge in New Medicare Study


Last-ditch, high-tech heroic treatments. Days in the hospital intensive care unit. You might think this is what makes dying in America so expensive - and that it’s where we should focus efforts to spend the nation’s healthcare dollars more wisely. But a new study finds that for nearly half of older Americans, the pattern of high spending on healthcare was already in motion a full year before they died.

Researchers with the University of Michigan and the Dartmouth Institute for Health Policy and Clinical Practice have discovered that there are four patterns that characterize end-of-life health care spending: High Persistant; Moderate Persistant; Progressive; and Late Rise. Each of these patterns of health spending indicates a markedly different way of engaging with the medical system, and one of them results in starkly higher costs.

This came as a surprise. Lead author of the study, Matthew A. Davis, PhD, MPH, an assistant professor at the University of Michigan School of Nursing, explains, “We were expecting to find the most common pattern to be explosive healthcare spending in the final months of life. In fact, only 12 percent of older adults in our study showed this ‘late rise’ pattern of healthcare spending.” The Late Rise pattern is actually the least expensive of the patterns, which could be viewed as problematic from a purely cost perspective, since 88% of patients follow another pattern.

Here’s a look at the four patterns and what they mean for cost and treatment in the aging US population:

High Persistent: This pattern is characterized by a high cost of medical care throughout the last year of life, slowly rising to a peak near the time of death. This is far and away the most expensive pattern, accounting for a median of $59,394 in costs during the last year of life. It is also the largest group, including more than half of the Medicare participants studied. This group had more than twice as many outpatient visits to medical specialists, and were more likely to spend time in medical facilities and receive life-prolonging treatments – such as a respirator, dialysis, or feeding tube.

Moderate Persistent: This group made up about 29% of patients included in the study. Patient costs started moderately high towards the beginning of the last year of life, dipped down slightly towards the middle, and then spiked at the end. These patients had a median health care cost of $18,408 in their last year of life.

Progressive: This group is the smallest, accounting for only 10% of patients, but the costs associated with this group are second-highest, weighing in at $39,036 median cost in the last year of life. Individuals in this group had very low spending early on, but saw their expenses rise markedly throughout the course of the year. “This group was also the most likely to use hospice care, perhaps because they and their families and physicians had a good sense that they did not have long to live.”

Late Rise: This is another small group, with only 12% of the total. The Late Rise group also has the lowest costs – a median of $11,116 in the last year of life. People in this group had very low health spending until the last months before death. They had far fewer physician visits or hospital stays, and often experienced no chronic conditions. This group was more likely to die during a hospital stay that included time in the ICU. They had the second-highest use of life-prolonging treatments.

Why do different individuals end up in one of these four groups? Researchers found that the primary factor in end-of-life cost patterns is not the type of disease, but rather the number of different health conditions that an individual is experiencing.

The study – which included data from nearly 1.3 million Americans aged 66 to 99 who died during the period studied - accounted only for Medicare spending, and did not include out-of-pocket or prescription drug spending.

Source: University of Michigan Health, 6/15,