Medical care costs at the end of life among older adults with cancer: a national health insurance data-based cohort study

Abstract

Objective

Along with aging, the elderly population with cancers is increasing. The costs of end-of-life (EOL) care are particularly high among cancer patients. The purpose of this study was to investigate the trends in medical costs in the last year of life among older adults with cancer.

Design, setting, and participants:

Using the Health Insurance Review and Assessment Services (HIRA) database for the period 2016–2019, we identified older adults aged ≥ 65 years who had a primary diagnosis of cancers and high-intensity treatment at least once in the intensive care unit (ICU) of tertiary hospitals.

Main outcomes and measures:

High-intensity treatment was defined as receiving at least one of the following treatments: cardiopulmonary resuscitation, mechanical ventilation, extracorporeal membrane oxygenation, hemodialysis, and transfusion. The EOL medical treatment costs were calculated by dividing periods 1, 2, 3, 6, and 12 months from the time of death, respectively.

Results

The mean total EOL medical expense per older adult during the year before death was $33,712. The cost of EOL medical expenses for three months and one month before subjects’ death accounted for 62.6% ($21,117) and 33.8% ($11,389) of total EOL costs, respectively. Among subjects who died while receiving high-intensity treatment in the ICU, the costs associated with medical treatments that occurred during the last month before death were 42.4% ($13,841) of the total EOL expenses during the year.

Conclusion

The findings indicate that EOL care expenditures for the older population with cancer are highly concentrated until the last month. The intensity of medical care is an important and challenging issue in terms of care quality and cost suitability. Efforts are needed to properly use medical resources and provide optimal EOL care for older adults with cancer.

Introduction

Cancer is a leading cause of death; in 2019, cancer accounted for 27.5% of deaths in South Korea.¹ In particular, among the elderly population over 65 years, the mortality rate from cancer has continuously increased from 122.4 (per 100,000 population) in 2000 to 158.2 in 2019.² Cancer patients are treated with multiple drugs and procedures for the management of symptoms and comorbid conditions. Additionally, a considerable proportion of cancer patients continue to receive intensive care near their end of life (EOL).³ South Korea has a national health insurance system that covers approximately 98% of the overall Korean population, and most medical procedures are reimbursed on a fee-for-service basis.⁴ Under such circumstances, cancer-related medical expenditures can be a huge burden on national health insurance finances.

The pain and disability caused by disease can increase the burden on patients and their family members for a long time before death, not only physically and mentally, but also economically. In 2018, the proportion of medical expenditure spent by Korea in gross domestic product (GDP) was 7.6%. Although this proportion is lower than the average one of organization for economic co-operation and development (OECD, 8.8%), the rate of increase in medical expenditure over the past five years in South Korea is the fastest among OECD countries.⁵ Medical expenses for the elderly ≥ 65 years continue to increase, and medical expenses per elderly person were approximately three times higher than that of the entire population in 2018.² These data show that a surge in medical expenses due to an aging population will increase the burden on both individuals and national health insurance finances.

Given the high risk of morbidity and increased access to health care services, it is not surprising that healthcare costs increase with age. However, in addition to age, income, residence area, type of disease, and care at the EOL are significant factors contributing to the increase in medical expenses.^6,7 In particular, there has been an increasing number of recent studies reporting medical expenses, which are intensively invested at the EOL and impending death, as a factor in the surge in medical expenses.^3,8 In a Canadian cohort study,⁸ approximately 10% of government-funded health expenditures were spent on health care in the last year of life, and EOL care costs rose sharply in the last three months prior to death. The costs of EOL care are particularly high among patients with cancer. The cancer cohort had significantly higher total health care costs of EOL than those without cancer in the United States and Australia.^6,9

Understanding EOL care costs can provide preliminary data on the factors that can increase the burden on the national health care budget. However, little is known about recent trends in medical care costs at the EOL among cancer patients in South Korea. Therefore, this study aimed to investigate the trends in medical costs for the last year of life among older adults with cancer.

Methods

Results

Discussion

This descriptive cohort study utilized national health insurance claims data from South Korea. We investigated medical care costs among older adults with one of the 12 cancers associated with a high mortality rate. Moreover, we examined EOL costs in the last year of life among patients with cancer. Our findings show that the EOL costs of medical treatments spent by older adults increase as the subjects are near the end of their lives.

The elderly population is rapidly growing worldwide as life expectancy increases due to advances in medicine and technology. According to the World Health Organization (WHO), by 2050, it is estimated that approximately one-fifth of the world’s population will be over 60 years old.¹⁵ The pace of population aging in South Korea has also increased dramatically. It is expected that the population aged 65 years or older will account for more than 40% of the total population by 2060.² The life expectancy at birth in 2018 was 82.7 years, while the health-adjusted life expectancy (HALE) was 64.4 years in South Korea.¹⁶ Life expectancy at birth refers to how long a newborn can expect to live, on average, if current death rates do not change.¹⁷ HALE represents the number of years in full health that an individual can expect to live given the current morbidity and mortality conditions.¹⁸ Many people want to live a long and healthy life. However, statistics indicate that we may live with disease for about 20 years from the age of 65 to the end of our life.

As the aging population progresses, the elderly population with cancer is increasing, and the financial burden caused by cancer is also expected to increase. According to statistics in South Korea, ¹⁹ the population aged ≥ 60 years (56.5%) received more cancer-related treatments compared to subjects of other age groups (2.5–21.6%) in 2019. In cohort studies analyzing data from cancer patients, ^3,20 the mean monthly inpatient costs for acute myeloid leukemia (AML) increased from $5,465 12 months before death to $15,033 in the last month. ³ Additionally, approximately 70% of the total medical expenditure during the last year of life among cancer patients was spent in the last 6 months. ²⁰ The pattern of increased EOL care costs was similarly observed in other countries studies. ^21–23 Substantial groups of severely ill deceased patients underwent intensive medical treatment until shortly before death in Switzerland. ²¹ Non-Hispanic (NH) Asian, NH black, and Hispanic patients with lung cancer were likely to receive intensive care in their final month of life in the United States. ²³ Furthermore, the Australian cancer cohort had significantly higher rates of health service use and 27% higher total healthcare costs than those without a cancer history. ²² These findings suggest that the medical expenses during EOL of elderly cancer patients might be substantial, which can place a great burden on the national medical finances.

Our findings indicated the total medical treatment costs and high-intensity care costs incurred during the recent ICU admissions among the older population with cancer. The costs for high-intensity care accounted for 6.4% ($849.30) of the total medical treatment costs. High-intensity care costs seem to account for a small proportion of total treatment costs. However, the actual cost associated with high-intensity care is expected to be much higher, considering that cancer is a chronic disease and can lead to repeated ICU admissions in severe cases. Additionally, this study might partially analyze medical costs because the HIRA dataset included only cost information with codes for specific treatment or procedures. According to our previous analysis work, ¹⁴ the annual cost of high-intensity care has increased steadily from 2016 to 2019. Considering that 95% of inpatient treatment costs are covered by national health insurance when a subject is diagnosed with registered cancer in South Korea, ²⁴ high-intensity medical expenditures related to cancer can be a financial burden on the health care system.

In this study, the total medical care costs and costs of high-intensity treatment varied according to age and sex. The costs of medical treatments for those aged 65–69 years were significantly higher than those aged > 85 years. A similar trend has been observed in other studies.^22,25 Deceased elderly aged over 90 years at death had 20% lower health care costs than those aged 80–84 years in Australia.²² In a Taiwanese national cohort study of elderly patients (≥ 60 years) with chronic kidney disease,²⁵ the care costs were lower among subjects with advanced ages: every 10-year increase in age was associated with a 3% reduction in 30-day EOL inpatient expenses. Additionally, our results showed differences in medical treatment costs according to sex. The total medical treatment cost was higher in men, whereas the cost of high-intensity treatment was higher in women. These results are consistent with those of Chen and colleagues,²⁵ who reported in Taiwanese study that EOL medical expenses were higher among women (3%; 95% CI, 0–5%). The cost of transfusion was higher in women under 80 years than in men of the same age in our study. This might be one of the factors related to the difference in high-intensity care costs between men and women. However, it is difficult to compare these results, as there are few studies that present the costs of various types of high-intensity treatment and analyze the difference in medical costs between men and women.

Additionally, this study provides recent evidence on the high costs of EOL cancer care among older adults that continue to increase until the last month of life. The total medical expenses were approximately $32,600 for the last year of life, and the cost incurred during one month before death was about one-third of the total EOL cost. According to study by Park and Song, ³ the monthly inpatient costs of cancer patients increased steeply from 2 months prior to death between 2013 and 2014 in South Korea. These findings indicate that many Korean elderly cancer patients are likely to receive invasive and aggressive treatment, even to the point of imminent death. The trend of high-intensity care costs is similarly observed in cohort studies in other countries such as the US, ^26,27 Canada, ⁸ and Taiwan. ²⁸ EOL care costs during the final 4 months of life were about $10,000 higher for cancer patients than for those without cancer in the US, ²⁶ and cancer patients were more likely to use intensive inpatient treatments ($23,938 vs. $17,856). In a Canadian cohort study, ⁸ acute care costs increased rapidly in the last 120 days. Likewise, the EOL care expenditure in cancer decedents was highly concentrated in the last few months in Taiwan ²⁸ ; total EOL care expenditures incurred in the last 1, 3, and 6 months were 32.9%, 52.2%, and 72.5%, respectively. Based on these findings, it can be seen that EOL care expenditures associated with high-intensity treatment for older populations with cancer are highly concentrated in the last month.

Medical expenses spent in the last year of the subject’s life indicate the intensity of EOL treatment. This study suggests the likelihood of unnecessary and futile medical spending at the EOL. In a longitudinal multi-institutional cohort study,²⁹ patients who had discussed their wishes for EOL care with physicians were more likely to receive care that was consistent with their preferences. Among patients who received no life-sustaining treatments, physical distress was lower in patients for whom such care was consistent with their preferences. Furthermore, a cancer patient’s documenting preferences against resuscitation were associated with better quality of life in the week before death.³⁰ With the implementation of the LST Decision Act¹³ since 2018, cancer patients at the terminal stage have the right to express their intentions regarding EOL medical treatments to their physicians and receive legal guarantees in South Korea. Accordingly, the public has become highly interested in the quality of care at the EOL. To avoid the financial pressure of aggressive EOL care, physical suffering, emotional burden, and failed expectations for care, policy makers and healthcare providers need to focus on the controllable causes that influence accelerating futile EOL care expenditures.

This study is limited in that the HIRA database included only medical care services that were reimbursed by the national health insurance system. Medical services that were paid by patients outside the pocket were excluded from the analysis. Moreover, the HIRA dataset included limited clinical information, such as the patient’s clinical exam results, which can influence cancer care costs. This study only included information on older adults with cancer treated at tertiary hospitals, so it may not be representative of EOL cancer patients in South Korea. Despite these limitations, this study is significant in that it provides preliminary data to understand the current status of medical care costs at the EOL for cancer patients. Future research should focus on investigating the clinical factors that influence cancer care costs and examining total medical expenditure, including non-reimbursable services costs, to estimate the entire economic burden of cancer care.

Conclusion

Findings indicate that EOL care for older populations with cancer is highly concentrated until impending death. Medical care costs incurred in the last month accounted for one-third of the total EOL expenditure. Futile high-intensity treatments at the EOL not only place physical, psychological, and economic burdens on patients and their families, but also increases the financial burden on the national health care system. The intensity of EOL care is an important and challenging issue in terms of care quality and cost suitability. Continuous assessment of the appropriateness of medical resource use at the EOL is required to reduce undue burden on the patient, families, and insurance system and to provide optimal care.

Declarations

Ethics approval and consent to participate: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by Pusan National University (PNU) Institutional Review Board (PNU IRB/2021_53_HR) and individual consent for this retrospective analysis was waived.

Consent for publication: Not Applicable

Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors have no conflicts of interest or funding sources to declare.

Funding: None

Authors' Contributions: T Kim, JM Jo and Y Lee. Data curation: JM Jo and Y Lee. Validation: T Kim. Writing – original draft: JM Jo and Y Lee. Writing – review: T Kim.

Acknowledgements: None

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