March 01, 2015

The Age-Cost Connection

It’s been well known for a long time that the amount Medicare spends on patient care every year increases with age. That’s not entirely surprising—after all, 80-year-olds are in general less healthy than 70-year-olds, so they need and receive more medical care. But is there an age when per capita spending stops going up, or even falls? If you think there is, guess what age that happens. Why? What would cause spending to level off? A recent article in Health Affairs gives some of the answers, at least about the facts.

Examining Medicare data from 2000 to 2011 for fee-for-service beneficiaries, the authors confirm that as recently as 2011, Medicare per capita spending rose with age, peaking at age 96 and then gradually declining. Spending for 96-year-olds averaged $15,145 compared to less than half that, or $7566, for 70-year-olds. What’s really fascinating is that in 2000, the age at which Medicare per capita spending peaked was 92, and it’s been steadily increasing ever since.

Before we can speculate about why, we need to understand what the money is being spent on. The study answers this question as well. For nonagenarians, much of the spending goes to skilled nursing facilities (that doesn’t mean long stay nursing homes, which aren’t covered by Medicare, but rather short term, post-acute or rehabilitative care). This finding doesn’t imply that hospital spending goes down; on the contrary, spending on inpatient hospital services remains a relatively constant share of per capita spending until patients reach their late 90s.

Translation: older people use a lot of medical services. They use more and more until they are close to 100 and that includes hospital care, along with hospice and skilled nursing facility care. Evidently our view of what constitutes reasonably treatment has been shifting over time—we used to think that it was all right to treat octogenerians aggressively, but we drew the line at nonagenerians. Now we’re treating nonagenarians aggressively and drawing the line at centenarians.

There is one bit of promising news, one hint that at least some patients and doctors are thinking twice about subjecting the oldest and frailest to all the technology we can muster. If we look at per capita spending the year people die, we find that Medicare spent $43,000 on 70-year-olds but only $20,000 on centenarians. The difference was due almost entirely to a disparity in hospital use. Apparently, it’s easier to recognize or perhaps to accept that a 100-year-old is dying, and to tailor treatment accordingly, than to accept that a 70- or even a 90-year-old is dying. But once we do acknowledge the inevitable, we restrain our impulse to try to prolong life, whatever the cost both to individual dignity and to the nation’s pocketbook.

Maybe, just maybe, we will come to accept that there is a price to pay for invasive treatment even when death is not quite so imminent, and that a different kind of treatment may be more humane for those who are physically frail or demented, regardless of age.

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