Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or Older, 1999-2013

Abstract

Importance: In a period of dynamic change in health care technology, delivery, and behaviors, tracking trends in health and health care can provide a perspective on what is being achieved.

Objective: To comprehensively describe national trends in mortality, hospitalizations, and expenditures in the Medicare fee-for-service population between 1999 and 2013.

Design, setting, and participants: Serial cross-sectional analysis of Medicare beneficiaries aged 65 years or older between 1999 and 2013 using Medicare denominator and inpatient files.

Main outcomes and measures: For all Medicare beneficiaries, trends in all-cause mortality; for fee-for-service beneficiaries, trends in all-cause hospitalization and hospitalization-associated outcomes and expenditures. Geographic variation, stratified by key demographic groups, and changes in the intensity of care for fee-for-service beneficiaries in the last 1, 3, and 6 months of life were also assessed.

Results: The sample consisted of 68,374,904 unique Medicare beneficiaries (fee-for-service and Medicare Advantage). All-cause mortality for all Medicare beneficiaries declined from 5.30% in 1999 to 4.45% in 2013 (difference, 0.85 percentage points; 95% CI, 0.83-0.87). Among fee-for-service beneficiaries (n = 60,056,069), the total number of hospitalizations per 100,000 person-years decreased from 35,274 to 26,930 (difference, 8344; 95% CI, 8315-8374). Mean inflation-adjusted inpatient expenditures per Medicare fee-for-service beneficiary declined from $3290 to $2801 (difference, $489; 95% CI, $487-$490). Among fee-for-service beneficiaries in the last 6 months of life, the number of hospitalizations decreased from 131.1 to 102.9 per 100 deaths (difference, 28.2; 95% CI, 27.9-28.4). The percentage of beneficiaries with 1 or more hospitalizations decreased from 70.5 to 56.8 per 100 deaths (difference, 13.7; 95% CI, 13.5-13.8), while the inflation-adjusted inpatient expenditure per death increased from $15,312 in 1999 to $17,423 in 2009 and then decreased to $13,388 in 2013. Findings were consistent across geographic and demographic groups.

Conclusions and relevance: Among Medicare fee-for-service beneficiaries aged 65 years or older, all-cause mortality rates, hospitalization rates, and expenditures per beneficiary decreased from 1999 to 2013. In the last 6 months of life, total hospitalizations and inpatient expenditures decreased in recent years.

Figure 1. Trends in Observed All-Cause Mortality Rates in the Medicare Population, 1999–2013

The symbols around each trend line represent the observed mortality rates for each year. All Medicare beneficiaries aged 65 years or older (square), Medicare beneficiaries aged 65 years or older who were enrolled in the Fee-for-Service plan for 1 or more month (circles), as well as Medicare beneficiaries aged 65 years or older who were enrolled in a Medicare Advantage program for the full duration for the year (diamonds) are shown. Lines were smoothed using the loess method (local regression). The numbers of Medicare beneficiaries aged 65 years or older in each year and plan are shown in Table 1.

Figure 2. Maps Showing Trends in Risk-Standardized All-Cause Deaths and Hospitalizations among Fee-for-Service Beneficiaries for Individual U.S. Counties in 1999 and 2013

U.S. counties are shaded according to the risk-standardized all-cause mortality rates (%) (top 2 panels) and the number of risk-standardized hospitalizations (bottom 2 panels) per 100,000 person-years of enrollment in the Medicare Fee-for-Service program: counties with the lowest death and hospitalization rates in 1999 were shaded green, while those with the highest death and hospitalization rates in 1999 were shaded red. Counties are shaded white if there were missing data that precluded the calculation of death, or hospitalization rates. The same legend was used for the panels describing mortality and hospitalization rates in 2013. Both all-cause mortality and hospitalizations were for all beneficiaries enrolled for 1 or more months in Medicare Fee-for-Service. For 1999 and 2013, respectively, there were 27,552,139 and 30,148,234 unique Medicare Fee-for-Service beneficiaries aged 65 or older, representing 26,147,690 and 28,834,706 person-years of enrollment. Data from Puerto Rico were included to estimate the national rates but were not included in the maps. For Puerto Rico, the risk-standardized mortality rate decreased from 4.97% (95% CI 4.91 to 5.04) in 1999 to 3.64 (95% CI 3.55 to 3.73) in 2013; the risk-standardized hospitalization rate per 100,000 person-years decreased from 29,038 (95% CI 27,891 to 30,184) in 1999 to 17,432 (95% CI 16,775 to 18,089) in 2013.

Figure 3. Trends in Observed (A) Hospitalization Rates and (B) Hospitalization-Related Outcomes in the Medicare Fee-for-Service Population, 1999–2013

A. Trends in Observed Hospitalization Rates: Rates for 1 or more hospitalizations (circle) and total hospitalizations (diamond) are shown in the figure and Table 3; hospitalizations for major surgical care are shown in Table 3. They all declined over time. The symbols around each trend line represent the observed hospitalization rates for each year. Lines were smoothed using the loess method (local regression). B: Trends in Observed In-Hospital, 30-Day, and 1-Year Mortality Rates: Among hospitalized patients: In-hospital (diamond), 30-day (square), and 1-year (circle) mortality. The symbols around each trend line represent the observed mortality rates for each year. Lines were smoothed using the loess method (local regression).

Figure 3. Trends in Observed (A) Hospitalization Rates and (B) Hospitalization-Related Outcomes in the Medicare Fee-for-Service Population, 1999–2013

A. Trends in Observed Hospitalization Rates: Rates for 1 or more hospitalizations (circle) and total hospitalizations (diamond) are shown in the figure and Table 3; hospitalizations for major surgical care are shown in Table 3. They all declined over time. The symbols around each trend line represent the observed hospitalization rates for each year. Lines were smoothed using the loess method (local regression). B: Trends in Observed In-Hospital, 30-Day, and 1-Year Mortality Rates: Among hospitalized patients: In-hospital (diamond), 30-day (square), and 1-year (circle) mortality. The symbols around each trend line represent the observed mortality rates for each year. Lines were smoothed using the loess method (local regression).