Dying in America is an expensive process, with about one in four Medicare dollars going to care for people in their last year of life. But for African Americans and Hispanics, the cost of dying is far higher than it is for Whites.
And despite years of searching for the reason, no one has quite figured out why.
[Photo: Dr. Kenneth M. Langa]
A new University of Michigan study tried to get to the bottom of this expensive mystery with the most detailed study to date. The team published their findings in the Journal of the American Geriatrics Society.
Unlike other kinds of health cost disparities, they didn’t find that the difference could be explained by differences in patients’ income, education, medical conditions or other individual factors such as use of hospice. The differences also persisted after they took into account general health spending patterns in a dying person’s area.
The team also took into account specific factors related to the unique circumstances that are present at the end of life – the first time this has been done. These indicators of patients’ own preferences still didn’t explain the differences in cost.
As a result, the researchers conclude that something bigger, rooted in the health care system as a whole, must be going on. After all the other factors were figured in, the cost of that last six months of life was $7,100 more expensive to the Medicare system for Blacks, and $6,100 more expensive for Hispanics, compared with Whites.
“We need to look harder for the causes of disparities in end-of-life care costs, and look at factors on the provider level and health system level, including family dynamics that may come into play,” says Dr. Elena Byhoff, who led the study while she was a Robert Wood Johnson Clinical Scholar at U-M and is now at Tufts Medical Center.
Dr. Byhoff and her colleagues, including U-M end-of-life care researchers SPH professor Dr. Kenneth Langa, and Dr. Theodore Iwashyna, hope that their study will add to the broader conversation about how to encourage good patient-provider-family interactions in patients’ final years, including the difficult but important questions about advance planning for end-of-life care. Whites were twice as likely as Blacks and Hispanics to have an advance directive document in place in the study.
New Medicare coverage for doctor visits that include such discussions may help, Dr. Byhoff says. But providers must also act on patients’ wishes as spelled out in advance directives, and families must understand and honor those wishes when the patient can no longer speak for him or herself.
Previous work by Dr. Langa and others has shown that end-of-life care costs tend to be lower for patients who have spelled out their wishes to limit treatment ahead of time.