Health Insurance and Out-of-Pocket Costs in the Last Year of Life Among Decedents Utilizing the ICU

Objectives: Use of intensive care is increasing in the United States and may be associated with high financial burden on patients and their families near the end of life. Our objective was to estimate out-of-pocket costs in the last year of life for individuals who required intensive care in the months prior to death and examine how these costs vary by insurance coverage. Design: Observational cohort study using seven waves of postdeath interview data (2002-2014). Participants: Decedents (n = 2,909) who spent time in the ICU at some point between their last interview and death. Interventions: None. Measurements and Main Results: Two-part models were used to estimate out-of-pocket costs for direct medical care and healthrelated services by type of care and insurance coverage. Decedents with only traditional Medicare fee-for-service coverage have the highest out-of-pocket spending in the last year of life, estimated at $ 12,668 (95% CI, $ 9,744-15,592), second to only the uninsured. Medicare Advantage and private insurance provide slightly more comprehensive coverage. Individuals who spenddown to Medicaid coverage have 4x the out-of-pocket spending as those continuously on Medicaid. Conclusions: Across all categories of insurance coverage, out-ofpocket spending in the last 12 months of life is high and represents a significant portion of assets for many patients requiring intensive care and their families. Medicare fee-for-service alone does not insulate individuals from the financial burden of high-intensity care, due to lack of an out-of-pocket maximum and a relatively high copayment for hospitalizations. Medicaid plays an important role in the social safety net, providing the most complete hospital coverage of all the insurance groups, as well as significantly financing long-term care.