Out-of-pocket spending and burdensome care for older adults with serious illness - PROJECT SUMMARY/ABSTRACT Over 40 million people in the U.S. live with serious illness, many of whom experience significant financial impact due to the high costs, utilization, and risk of mortality that accompany serious illness. Older adults in particular have a greater number of chronic conditions and lower income to manage increased health spending as they retire. One quarter of older adults experience out-of-pocket spending (OOPS) in the last five years of life that exceeds their entire household assets. Despite the disproportionate impact of high OOPS on older adults with serious illness, the underlying drivers of high OOPS, and the potential care consequences from high OOPS for this population, are inadequately understood. Prior studies show drivers of higher OOPS for seriously ill older adults include serious illness type, health care utilization, insurance type, and living situation, among other factors. However, none have examined how insurance generosity affects high OOPS for seriously ill older adults. Insurance generosity varies within insurance types and can be dictated by state-level policy. Omitting insurance generosity from models of high OOPS excludes a highly modifiable factor that could mitigate high OOPS and their consequences. Such consequences of high OOPS include potentially burdensome care (e.g., emergency department reliance, days away from home, care transitions in the last three days of life, and in-hospital death), some of which have been associated with lower care quality at end-of-life as rated by patients and families; and depression, which has a well-established relationship with decreased wealth. Examining insurance generosity at the onset of serious illness, when OOPS is typically most concentrated, may further illuminate a path through which potentially burdensome care, depression, and care quality could be addressed. In this project, we will leverage rich health and financial data from the nationally representative Health and Retirement Study (HRS) to a) determine the relative contributions of insurance generosity, serious illness type, and other factors to high OOPS among Medicare beneficiaries over 65 with new-onset serious illness, and b) test the association of insurance generosity during serious illness onset with subsequent burdensome care and depression among Medicare beneficiaries over 65. Such analyses will provide a more complete picture of the factors contributing to high OOPS for a population that is most affected, and also reveal novel insights on the relationship of insurance generosity with burdensome care and depression. These data can guide researchers, health systems, policy makers, and the public towards consideration of insurance generosity as a possible target for intervention. Mitigating high OOPS and its consequences at serious illness onset has the potential to interrupt a cascade of wealth depletion, worsened depression, health decline, and escalating care needs for older adults with serious illness.
