By Hannah Hoag
The High End Cost of Cancer
Blacks and Hispanics spend more on end-of-life care than whites
By Hannah Hoag
Throughout most of their lives, blacks and Hispanics spend less on medical services than whites. But at the end of life, the trend is reversed—there is a sudden burst of spending during the last six months of care among racial and ethnic minorities. So says a study in the March 9 Archives of Internal Medicine, which suggests that much of the cost is tied to life-sustaining interventions.
A second report in the same issue of the journal offers further insight into the disparity: End-of-life conversations between physicians and patients with advanced cancer correlate with the costs of health care in the last week of life.
The first study looked at Medicare expenditures in the last six months of life among nearly 159,000 people who had died. For all causes of death, the cost for whites averaged about $20,200; whereas the average cost for blacks and Hispanics was about $26,700 (32 percent more) and $31,700 (57 percent more), respectively. When the cause of death was cancer, the cost of end-of-life care for blacks and Hispanics was 16 percent more and 36 percent more, respectively, than it was for whites.
Health care services—including end-of-life care—tend to be more expensive in urban areas. And because minorities are more likely than whites to be urban dwellers, researchers thought this geographic difference might explain the increase in end-of-life costs. However, it turns out that’s not the whole picture.
“Even after adjusting for location, we see that roughly half of the difference in cost is associated with using aggressive intervention at the end of life,” says health services researcher Amresh Hanchate of the Boston University School of Medicine, who worked on the study. Admission to intensive care units, resuscitation and mechanical ventilation were more common among minorities than whites.
Hanchate cautions that the study looked only at patients who died, making it difficult to know if others benefited from the same procedures. Nor did the research reveal why these differences among racial and ethnic groups exist.
In the second study, researchers found that medical costs were 36 percent lower among patients who discussed end-of-life issues with their physicians compared with those who did not, largely because the use of intensive interventions was lower. The research team led by Holly Prigerson, the director of the Center for Psycho-oncology and Palliative Care Research at the Dana-Farber Cancer Institute in Boston, also found that patients with higher health care costs generally had a worse quality of death.
Personal, religious or ethnic differences may influence an individual’s choice to pursue more aggressive treatments, something Prigerson fully supports. Yet she worries many patients and families may not have the information they need to make an informed decision about treatment (see the sidebar "Thinking It Through").
“There is a communication problem,” says Prigerson. “Everyone wants to [be able to] offer hope, but there are situations where that can’t be the case.”
“Often doctors wait for patients to ask [questions], and patients wait for doctors to provide the information,” notes Esme Finlay, an oncology and palliative care fellow at the University of Pennsylvania in Philadelphia, who was not involved in the two new studies. “It’s a huge missed opportunity.”