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National Healthcare Disparities Report, 2003

Findings on Disparities in Medicare Expenditures at the End of Life

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By Lisa R. Shugarman, Ph.D. and Joanne Lynn, M.D., M.S.


Sample:

We restricted our analyses to elderly Medicare fee-for-service beneficiaries who were continuously enrolled in both Part A (Hospital Insurance) and Part B (Supplemental Medical Insurance) for 36 months prior to their death between January 1, 1996 and December 31, 1999. We excluded beneficiaries qualifying for Medicare with ESRD or disability and those enrolled in Medicare+Choice capitated coverage. Because the 'other' race category comprised a small proportion of our sample (2.0%), we excluded them, retaining only white and black beneficiaries. Our resulting analytic sample includes decedents age 68 and older (N=241,047).

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Variables:

The principal outcome measure is total annual Medicare expenditures for each of three years prior to death. Medicare expenditures are the sum of inflation-adjusted (to 1999 dollars) Medicare program payments to providers for each of six service types: inpatient, outpatient, skilled nursing, home health, hospice, and physician. Deductibles, co-insurance, durable medical equipment, payment by other insurance, and out-of-pocket expenses are not included.

Other measures include age, gender, race, Medicaid enrollment, income, rural/urban setting, and co-morbidities. We derived age, gender, race and Medicaid enrollment from the Medicare Denominator files. Age at death was calculated from dates of birth and death and collapsed into three cohorts: 68-74, 75-84, and 85 and older. We categorized race as white or black. Medicaid enrollment reflects any state buy-in to Medicare during the last year of life. We linked the Medicare Denominator file with zip code level census data and obtained the median household income for the beneficiaries' zip codes of residence. We defined three income categories: < $20,000, $20,000 to $34,999, and > $35,000. We linked the Urban Influence Codes from the Area Resource File to the Denominator file by state and county of residence to capture urban and rural residence of decedents (MSA/non-MSA) (Gelfi and Parker 1995).

We screened all claims for mention of 16 co-morbid conditions: myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, chronic obstructive pulmonary disease, rheumatoid arthritis, peptic ulcers, chronic liver disease and cirrhosis, diabetes, hemiplegia, quadriplegia, renal failure, malignant neoplasms, metastatic cancer, and AIDS. We created a categorical variable to reflect those who had 0-2, 3-5, and 6 or more co-morbidities.

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Analyses:

We analyzed data using SAS statistical software, version 8.0 (SAS Institute Inc 1999). Using analysis of variance and the student's t-test for mean unadjusted expenditures, we described differences by gender, race, age, co-morbidity, Medicaid eligibility, urban/rural and income categories in each of the last three years of life. Due to the large sample size, almost all pair-wise comparisons were statistically significant at P < 0.0001. In each table, we mark only effects that were not significant at P<0.0001.

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Table Descriptions

Table 1 (Mean expenditures for the last year of life, by race):

Mean expenditures overall and for Caucasian and African-American Medicare decedents separately are presented along with standard errors by age, gender, Medicaid eligibility, urban/rural residence, co-morbidities, and area income. Only the last year of life expenditures are presented.

Table 2 (Mean expenditures for the last three years of life, by race):

Mean expenditures overall and for Caucasian and African-American Medicare decedents separately are presented along with standard errors by age, gender, Medicaid eligibility, urban/rural residence, co-morbidities, and area income. Mean expenditures are presented for each of the last three years of life.

Table 3 (Mean expenditures for the last year of life, by Medicaid eligibility):

Mean expenditures overall and for Medicaid and non-Medicaid eligible Medicare decedents separately are presented along with standard errors by age, gender, race, urban/rural residence, co-morbidities, and area income. Only the last year of life expenditures are presented.

Table 4 (Mean expenditures for the last three years of life, by Medicaid eligibility):

Mean expenditures overall and for Medicaid and non-Medicaid eligible Medicare decedents separately are presented along with standard errors by age, gender, race, urban/rural residence, co-morbidities, and area income. Mean expenditures are presented for each of the last three years of life.

Table 5 (Mean expenditures for the last year of life, by race and age):

Mean expenditures overall and for Caucasian and African-American Medicare decedents separately are presented along with standard errors by age, gender, co-morbidity categories, urban/rural residence, and area income. In this table, mean expenditures by gender, co-morbidity categories, urban/rural residence and area income are also stratified by age group. Only the last year of life expenditures are presented.

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References:

Gelfi, L.M. and T.S. Parker (1995). "A county-level measure of urban influence." Rural Development Perspectives 12(2).

SAS Institute Inc (1999). Cary, NC.

Return to Appendix B: Methods
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2003 National Healthcare Disparities Report

 

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