Health System and Beneficiary Costs Associated With Intensive End-of-Life Medical Services

Published in: JAMA Network Open, Volume 2, No. 9 (2019). doi: 10.1001/jamanetworkopen.2019.12161

Posted on on March 11, 2020

by Risha Gidwani, Steven M. Asch, Vincent Mor, Todd H. Wagner, Katherine Faricy-Anderson, Samantha Illarmo, Gary Hsin, Manali L. Patel, Kavitha Ramchandran, Karl Lorenz, et al.

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Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services.


To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life.

Design, Setting, and Participants

This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48,937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019.


American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days.

Main Outcomes and Measures

Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region.


Of 48,937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23,612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15,952 (95% CI, $15,676–$16,206; P < .001). The biggest contributor to these differences was $21,093 (95% CI, $20,364–$21,689) for intensive care unit stay, while the smallest contributor was $3460 (95% CI, $2927–$3880) for chemotherapy. Mean (SD) expected beneficiary costs for the last month of life were $133 ($50) for patients with no medically intensive service and $1257 ($408) for patients with at least 1 medically intensive service (P < .001).

Conclusions and Relevance

Given the low income of many elderly patients in the United States, the financial consequences of medically intensive services may be substantial. Costs of medically intensive services at the end of life, including patient financial consequences, should be considered by both physicians and families.

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