End of Life Expenditure
Patterns for Medicaid
Eligible Infants and Children
Caprice Knapp, PhD
Lindsay Thompson, MD MS
Bruce Vogel, PhD
Elizabeth Shenkman, PhD
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Background
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Annually, 50,000 children die from injuries,
congenital anomalies, cancer, and other
diseases
An additional 500,000 children are coping with
life-limiting illnesses
The goal of palliative care is to provide
comprehensive and effective care for children
and families (pain and symptom control) while
addressing health, spirituality, and emotional
well being
Limited information available
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Goals of our Study
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Describe the end of life usage patterns over
a diverse set of service categories
(inpatient, outpatient, emergency dept.,
pharmacy, skilled nursing, and hospice
care)
Investigate the association between
demographic and health status
characteristics on spending
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Census Characteristics
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N=1,282 infants and N=1,934 children who died from
2003-2006. All in Florida’s Medicaid program
Costs during the last 12 months of life
About 60% males (both infants and children)
More Black infants (37%) and more White children (40%)
than all other race categories (Hispanic and Other)
Less than 10% live in a rural area
Infants age=3 months, children=12
Average months enrolled for children=9
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Mean Expenditures (standard deviation) During the Last Year of Life for
Spenders, Percentage Incurring Expenditures
Infants
Children
Inpatient
$54,696
($88,826)
75%
$46,521
($74,142)
52%
Outpatient
$1,525
($5,731)
60%
$15,987
($38,463)
82%
Hospice
$955
($9,266)
3%
$11,292
($14,080)
10%
Skilled
Nursing
$21,275
($29,611)
1%
$88,117
($42,226)
4%
Total Costs
$51,800
($88,631)
85%
$54,873
($84,995)
87%
Health Status Characteristics
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Clinical Risk Groups (CRGs) were used to
classify children into one of six categories:
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Non Acute Non Chronic,
Significant Acute,
Chronic Minor,
Chronic Moderate,
Chronic Major, and
Unassigned.
More infants were classified as unassigned
(41%) and more children were classified with a
major chronic condition (35%)
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Analytical Strategy
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Two part models were used:
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Estimate the odds of having any expenditures,
For spenders only, estimate an ordinary least squares
(OLS) model,
Combine the results to determine the overall effects.
Outcome variables: expenditures for the service
categories
Expenditures are highly skewed so we log
transformed the dependent variables, and then
transformed them back for ease of interpretation.
Predictor variables: CRGs, months enrolled, and
demographics
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Results- Logistic Model
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CRGS had the greatest effect on the odds of incurring
any expenditures for both infants and children
Longer months enrolled increased the odds for
infants-- 15% inpatient to 58% total costs
Black infants had decreased odds versus Whites-35% less ED, 40% less Outpatient, and 35% less
Pharmacy
Black children had increased odds versus Whites-60% more ED costs
Hispanic infants had three times the odds of incurring
hospice costs than Whites.
Black children 50% less likely than Whites to incur
hospice expenses.
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Combined Results for the Overall
Effect on Cost
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More severe conditions increased total expenditures for children and infants.
• $5,673 for non-acute non-chronic children,
• $18,200 for significant acute children, and
• $38,300 for major chronic condition children.
Black and Hispanic infants and children had higher inpatient expenditures–
• $30,783 for White non-Hispanic infants,
• $50,484 for Black non-Hispanic infants, and
• $32,630 for Hispanic infants
Rural children had lower pharmacy expenditures–
• $4,024 for urban, and
• $3,098 for rural.
Hispanic infants had lower pharmacy expenditures–
• $253 for White non-Hispanic,
• $255 for Black non-Hispanic, and
• $83 for Hispanic
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Discussion
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For both infants and children:
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Health status had the greatest effect on spending
Months enrolled had positive effect
Age had a slightly negative effect for children
Race/ethnicity variables showed some expected and unexpected
results:
Expected
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Black and Hispanic infants spend less than Whites for pharmacy and
outpatient, and
Black and Hispanic children spend more on inpatient and emergency
department care than Whites.
Unexpected
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Hispanic infants are about 3 times more than White infants to use
hospice services, and
Children in rural areas spend more inpatient but less on pharmacy
than children in urban areas.
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Future Research
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What drives the differences in service
usage across racial groups?
Would the patterns of use differ if a
longer time span was used?
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