Predictors and Drivers of End-of-Life Medicare Spending Among Older Adults with Solid Tumors: A Population-Based Study

Purpose: Medicare patients who die from cancer are responsible for about 30% of annual Medicare spending, most of which occurs during the last 30 days of life. Yet, there are significant and persisting knowledge gaps regarding which factors contribute to this high-intensity EoL spending. To that end, we conducted a retrospective analysis of SEER-Medicare data to identify risk factors associated with high-intensity EoL spending among older adults who died of breast, prostate, lung, or colorectal cancer. Methods: We used multivariable linear regression to identify clinical, demographic, socioeconomic, and geographic characteristics associated with the total inflation-adjusted Medicare spending in the last 30 days of life, including reimbursements for services provided in inpatient and outpatient settings. The study subjects included U.S. Medicare beneficiaries aged 65 and older who died of breast, prostate, lung, or colorectal cancer between 2011 and 2015. Results: Among 59,355 decedents (49.2% female; 21.2% of a non-White race/ethnicity), the factors associated with greater EoL spending were an increased comorbidity burden, the female sex, the Black race, other races/ethnicities, stage III or IV disease, living in a more populated county, and state subsidization of patient Medicare premiums. The EoL spending was lower among older patients; patients living in the Midwest, South, or West; patients living in more rural areas; and patients with a poor performance status. The results were largely consistent across cancer types. Conclusions: Our findings can inform targeted intervention development for patients with cancer who are at a higher risk of high-intensity EoL spending, such as decision support tools that facilitate referrals to palliative care for high-risk patients.