Blacks, Hispanics Have Steeper End-of-Life Costs

Striking new research shows dying blacks and Hispanics have much steeper treatment costs than whites, sobering evidence that racial health-care differences continue right up until death.

It’s not that minorities are being charged more than whites. It’s that they tend to get more costly, intensive treatments including feeding tubes and other invasive medical procedures near death. That’s in sharp contrast with what often happens throughout their lives, when minorities are less likely than whites to get aggressive medical care.

The results raise a troubling question about whether medical resources for nonwhite patients are “misallocated over a lifetime,” with minorities receiving more treatment at the end, when there is little chance of improving or extending life, the study authors said.

The study appears in Monday’s Archives of Internal Medicine. {snip}

Medicare costs in those final months averaged $20,166 for whites. Among blacks, they were $26,704, about 30 percent higher; and among Hispanics, $31,702 or almost 60 percent higher. Those individual cost differences can add up to billions of dollars on a national scale, Emanuel said.

Theories behind care

Reasons why minorities receive more costly end-of-life care are unclear; the study had no data to explain that. But Emanuel and other doctors offered several theories.

{snip}

Distrust of doctors and suspicions about getting less attentive treatment than whites likely is another factor, the study authors said.

Also, because of cultural or spiritual beliefs, some minorities are more likely to hold out hope for a miraculous recovery, or to oppose letting doctors play God and hasten death by abandoning treatment, said Dr. Elbert Huang, a Chinese-American physician with the University of Chicago Medical Center.

Letting doctors withdraw aggressive end-of-life treatment is mostly a western European approach, Huang said.

{snip}

Because low-income minority patients often get less preventive medical care, they’re less likely than whites to have long-term relationships with doctors, Brawley said. [Dr. Otis Brawley is a black physician in Atlanta and chief medical officer for the American Cancer Society.] So physicians who treat them late in life may be strangers unwilling to “pull the plug” without knowing their wishes.

Also, Brawley said, black patients often have splintered families, and estranged relatives are in charge of making end-of-life decisions.

{snip}

“The breakdown of the family in certain cultures contributes somewhat to this phenomenon,” he said. “I’ve seen it so many times.”

[Editor’s Note: “Racial and Ethnic Differences in End-of-Life Costs: Why Do Minorities Cost More Than Whites?” et al., can be read or downloaded here. An account is required.]

Abstract

Background: Racial and ethnic minorities generally receive fewer medical interventions than whites, but racial and ethnic patterns in Medicare expenditures and interventions may be quite different at life’s end.

Methods: Based on a random, stratified sample of Medicare decedents (N = 158 780) in 2001, we used regression to relate differences in age, sex, cause of death, total morbidity burden, geography, life-sustaining interventions (eg, ventilators), and hospice to racial and ethnic differences in Medicare expenditures in the last 6 months of life.

Results: In the final 6 months of life, costs for whites average $20 166; blacks, $26 704 (32% more); and Hispanics, $31 702 (57% more). Similar differences exist within sexes, age groups, all causes of death, all sites of death, and within similar geographic areas. Differences in age, sex, cause of death, total morbidity burden, geography, socioeconomic status, and hospice use account for 53% and 63% of the higher costs for blacks and Hispanics, respectively. While whites use hospice most frequently (whites, 26%; blacks, 20%; and Hispanics, 23%), racial and ethnic differences in end-of-life expenditures are affected only minimally. However, fully 85% of the observed higher costs for nonwhites are accounted for after additionally modeling their greater end-of-life use of the intensive care unit and various intensive procedures (such as, gastrostomies, used by 10.5% of blacks, 9.1% of Hispanics, and 4.1% of whites).

Conclusions: At life’s end, black and Hispanic decedents have substantially higher costs than whites. More than half of these cost differences are related to geographic, sociodemographic, and morbidity differences. Strikingly greater use of life-sustaining interventions accounts for most of the rest.

Author Affiliations: Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts (Drs Hanchate, Kronman, and Ash); Lown Cardiovascular Research Foundation, Brookline, Massachusetts (Dr Young-Xu); and Department of Bioethics, National Institutes of Health, Bethesda, Maryland (Dr Emanuel).