Living Well at End of Life: Examining Transitions and Condition Trajectories at the End of Life

A small proportion of very high spenders constitute a large proportion of decedent spending and they have multiple settings transitions. While studies show that people want to die at home and minimize chaotic care in the last-year-of-life (LYOL), a subgroup of decedents has multiple settings changes, illness deterioration, and high spending.

Longitudinal analysis was performed on 1,195 decedents for three years from the Medicare Current Beneficiary Survey. We examined the top 10% of spenders and found the top decile spending decedents spent five times what others spent in LYOL because their service mix is significantly different. High-spending decedents spent seven times as much on hospitalization and six times as much on post-acute services compared to lower-spending decedents, but had shorter hospice stays.

Escalating health trajectories compound the difficulty of death for high-spending decedents. The high-spending decedents have a more drastic development of new chronic conditions and limitations in activities of daily living in LYOL. Almost half of higher-spending decedents reported a new chronic condition in LYOL. Diabetes and psychiatric disorders were more prevalent among higher spenders. They also had more difficulties communicating with doctors and in multiple settings.

Our closer look demonstrates that there is considerable variation in spending within the decedent population, and the variation appears to be associated with health and utilization trajectories. The question now is not how much decedents spend on healthcare, but how to flexibly execute their care to meet their needs in symptom management, choice and control, open communication, and quality of life.