Expenditure Patterns for Medicaid Eligible Children in the Last Year of Life

Research Objective: About 500,000 children cope with life-limiting conditions annually, yet little is known about their health care use patterns, particularly at the end of life. Our objective was to examine the predisposing (age, race/ethnicity) factors and diagnostic factors associated with health care spending patterns among Medicaid eligible children with life-limiting conditions during the last 12 months of life.

Population Studied: A census of infants (0 to 1 year) and children (1 to 21 years) enrolled in the Florida Medicaid program who subsequently died between July 2002 and July 2005 and had an identified life-limiting illness (N=891).

Study Design: This is a retrospective study. Florida's Medicaid program provided individual-level enrollment and claims/encounter data. Children were included in the analyses if they had a diagnosis that was life-limiting and died during the observation period. Ordinary least squares regression was used to examine the relationship between child characteristics and expenditures by type of service: inpatient, outpatient, emergency department (ED) and support services (i.e., home nursing, counseling, various therapies), taking into account diagnostic factors. Expenditures were adjusted and log-transformed. Finally, regression adjusted mean expenditures were compared for White and non-White children to identify differential spending in the last year of life.

Principal Findings: Infants and children had similar mean annual total expenditures ($75,000). Ninety-six percent of total expenditures for infants were inpatient; they represented only 63% for children. We also found that expenditures decreased in the last six months of life for children overall: -4.8% decrease for inpatient, -14.5% for ED, -15.3% for support services, and -8.3% for total costs; (p =0.00 for each category). Variations in health care expenditure patterns were also observed based on age and race/ethnicity Inpatient expenditures decreased for White and Hispanic children in the last 6 months of life; whereas Black non-Hispanic children had a 32% increase in inpatient expenditures. Unexpectedly, Hispanic children's expenditures for support services were ten times higher than White non-Hispanics.

Implications for Policy, Delivery, or Practice: Our analyses indicate that children are receiving a substantial portion of their care in inpatient settings during the last year of life, however further investigation is needed to better understand the racial/ethnic differences in end of life expenditures. Children with life-limiting conditions would likely benefit from placement in emerging palliative care programs designed to improve children's quality of life through provision of supportive services (home nursing, counseling, therapies) from the time of diagnosis until the time of death.