By Khandelwal, Nita MD, MS; White, Lindsay PhD, MPH; Curtis, J. Randall MD, MPH; Coe, Norma B. PhD
Critical Care Medicine, June 2019
Objectives: Use of intensive care is increasing in the United States and may be associated with high financial burden on patients and their families near the end of life. Our objective was to estimate out-of-pocket costs in the last year of life for individuals who required intensive care in the months prior to death and examine how these costs vary by insurance coverage.
Design: Observational cohort study using seven waves of post-death interview data (2002–2014).
Participants: Decedents (n = 2,909) who spent time in the ICU at some point between their last interview and death.
Measurements and Main Results: Two-part models were used to estimate out-of-pocket costs for direct medical care and health-related services by type of care and insurance coverage. Decedents with only traditional Medicare fee-for-service coverage have the highest out-of-pocket spending in the last year of life, estimated at $12,668 (95% CI, $9,744–15,592), second to only the uninsured. Medicare Advantage and private insurance provide slightly more comprehensive coverage. Individuals who spend-down to Medicaid coverage have 4× the out-of-pocket spending as those continuously on Medicaid.
Conclusions: Across all categories of insurance coverage, out-of-pocket spending in the last 12 months of life is high and represents a significant portion of assets for many patients requiring intensive care and their families. Medicare fee-for-service alone does not insulate individuals from the financial burden of high-intensity care, due to lack of an out-of-pocket maximum and a relatively high co-payment for hospitalizations. Medicaid plays an important role in the social safety net, providing the most complete hospital coverage of all the insurance groups, as well as significantly financing long-term care.
By Don McCanne, M.D.
About this great health care financing system we have that several politicians want to protect, as this study shows, “Across all categories of insurance coverage, out-of-pocket spending in the last 12 months of life is high and represents a significant portion of assets for many patients requiring intensive care and their families.” In fact, many end up depleting their assets and go on Medicaid.
We must think that there is something good about having an estate at the end of life since we have public policies that prevent modest estates from being depleted through estate taxes. So why do we tolerate a health care financing system that wipes out assets of those unfortunate enough to require intensive care services in the last year of life?
We’ve long known that Medicare alone was inadequate, but this study shows that all categories of insurance coverage may be inadequate, though adding Medicaid to Medicare provides a safety net but only after the patient’s assets are depleted.
The single payer model of Medicare for All, by covering all essential services and by eliminating out-of-pocket spending, prevents compounding the end of life with financial hardship, not to mention protecting residual assets for the benefit of a surviving partner or progeny.
This may not represent the most pressing need for health care financing reform, but it does represent the fact that we seem to be more concerned about taking care of the insurance industry by continuing to tolerate the hundreds of billions of dollars in administrative waste while continuing to tolerate the patients’ financial hardships that the insurance industry is supposed to prevent.
A Medicare public option would not prevent this since the study shows, “Among insured decedents greater than or equal to 65, those with only Medicare FFS had the highest estimated OOP costs in the last year of life in every cost category except for prescription drugs.” Allowing people to buy into Medicare will not provide adequate protection.
And allowing people to keep their employer-sponsored insurance when 60 million people leave their jobs each year? Come on!
We want real reform that takes care of everyone in a system we can afford – single payer improved Medicare for all.
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