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

Khandelwal, Nita MD, MS1; White, Lindsay PhD, MPH2; Curtis, J. Randall MD, MPH3; Coe, Norma B. PhD4,5

doi: 10.1097/CCM.0000000000003723
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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 post-death 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 health-related 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 spend-down to Medicaid coverage have 4× the out-of-pocket spending as those continuously on Medicaid.

Conclusions: Across all categories of insurance coverage, out-of-pocket 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 co-payment 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.

1Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA.

2Department of Health Services, University of Washington, School of Public Health, Seattle, WA.

3Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA.

4Department of Medical Ethics and Health Policy, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA.

5Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA.

The content is solely the responsibility of the authors and does not necessarily represent the official views of Agency for Healthcare Research and Quality or National Institute on Aging.

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Supported, in part, by the Agency for Healthcare Research and Quality (K12HS022982) and the National Institute on Aging (R01AG049815).

Dr. Khandelwal’s institution received funding from Agency for Healthcare Research and Quality (Grant: K12HS022982). Dr. White's institution received support from National Institute on Aging (NIA) (Grant: R01AG049815). Dr. Coe’s institution received funding from NIA, and she received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest.

This work was performed at the University of Washington, Seattle, WA.

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