JOURNAL OF PALLIATIVE MEDICINE

Volume 5, Number 5, 2002

© Mary Ann Liebert, Inc.

Age and Gender Differences in Health Care Utilization

and Spending for Medicare Beneficiaries
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in Their Last Years of Life

CHLOE E. BIRD, Ph.D.,1 LISA R. SHUGARMAN, Ph.D.,1 and JOANNE LYNN, M.D., M.A.2,3

ABSTRACT

Men’s and women’s health care experiences differ as they age. While increasing attention has
been focused on gender differences in health status, prevalence of illnesses, and access to
Journal of Palliative Medicine 2002.5:705-712.

quality care among older adults, little is known about differences in their health care in the
last years of their lives. This paper uses claims data for a 0.1% random sample of Medicare
beneficiaries who died between January 1, 1994 and December 31, 1998 to assess age and gen-
der differences among Medicare-eligible adults in their utilization of health care services in
the last year of life. Overall, age is much more important than gender in explaining most of
the variation in end-of-life care. The combination of being a Medicare beneficiary and being
sick enough to die appears to attenuate gender disparities in health care services utilization.

INTRODUCTION as premature birth, infection, heart disease, and

traumatic injury. Median life expectancy at birth

D ISPARITIES BETWEEN MEN AND W OM EN in their

experience of illness and health care are ev-
ident throughout their lifespans. These gender
disparities might arise largely from gender itself,
or from differences in age, or from a combination
of age, comorbidities, diagnoses, social roles,
poverty, or underlying physiologic differences.
Of these possible explanations for gender differ-
ences in health care utilization, among the most
difficult to separate are the effects of age and
gender.
END-OF-LIFE CARE
Advances in health care and in public health
interventions have enabled Americans to live
longer and to survive life-threatening events such
has reached 79.5 years for women and 73.8 years
for men.1 American adults now can typically ex-
pect to live well into their ninth decade.
One largely ignored result has been the emer-
gence of long-term, chronic disease as the major
pathway to death. An examination of Medicare
claims data found that in the year before death,
almost 90% of decedents had at least one of these
five illnesses: congestive heart failure, chronic ob-
structive pulmonary disease, stroke, dementia, or
cancer.2 These illnesses occasion a prolonged
course of increasing disability and illness prior to
death.
A second result is that financing of end-of-life
care largely occurs within Medicare. Of the 2.3
million Americans who died in 1997, roughly 2
million (86%) were Medicare beneficiaries. 2 Care
in the last year of life consumes approximately

1 RAND
Corporation, Santa Monica, California.
2 RAND Corporation, Arlington, Virginia.
3 Washington Home Center for Palliative Care Studies, Washington, D.C.

705
 706
27% of the Medicare budget and has done so con-
sistently over the past two decades.3 Medicare’s
financing policies are, by default, America’s pub-
lic policy on the financing of end-of-life care.
Researchers have raised the possibility that
there are gender disparities not only in care re-
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ceived by Medicare beneficiaries, but also in the
Medicare benefit structure relative to different
needs for care by elderly men and women.
Among both community dwellers and nursing
home residents, older women are less likely than
older men to be hospitalized, adjusting for dis-
ease type and severity.4,5 Miles and Parker6 ar-
gue that Medicare serves men better than women
because relatively adequate hospitalization cov-
erage contrasts with less adequate coverage for
nursing home care, community services, outpa-
tient medications, preventive health examina-
tions, and adaptive aids, than for hospital costs;
Journal of Palliative Medicine 2002.5:705-712.
they note that even though the women covered
by Medicare are older than men, Medicare dis-
tributes 12% more of its payments per beneficiary
per year for men. Furthermore, Cherouny and
Nadolski7 demonstrated that Medicare reim-
bursement for men was much higher than for
women for some comparably difficult procedures
(e.g., genital biopsies and pelvic surgery).
GENDER DIFFERENCES IN
END-OF-LIFE CARE
Gender differences in health care are well es-
tablished, but have not been examined at the end
of life. Such disparities in end-of-life care may
arise from at least four independent sources: (1)
men’s and women’s age at death; (2) the acute
and chronic conditions they experience; (3) dif-
ferential treatment, and (4) plan coverage. At age
65, women’s life expectancy exceeds men’s by 3.2
years.8 Differences in morbidity contribute to dif-
ferences in men’s and women’s health care uti-
lization at the end-of-life, because women are far
more likely than men to suffer from debilitating
chronic illnesses such as arthritis, cognitive de-
cline, and hearing and vision deficits.9 Although
women use health services more frequently than
do men throughout their lifespan, 10 multiple
studies have demonstrated that women receive
less aggressive care. For example, women are less
likely to receive expensive, high-technology ser-
vices, such as dialysis and transplantation, timely
BIRD ET AL.
diagnosis of lung cancer, and specific diagnostic
and therapeutic interventions for heart disease. 11
CONCEPTUAL FRAMEWORK
One explanation of gender differences in health
care is the difference in the age at which men and
women become sick enough to need access to reg-
ular and intensive health care services. Some
studies suggest that clinicians treat younger pa-
tients differently than they treat older patients,
adjusting for disease severity and patient prefer-
ences.3,12–14 The apparent gender difference in
hospitalization rates stated previously may re-
flect the age difference between male and female
patients and the tendency of clinicians to treat
younger patients more aggressively.
An alternative explanation from the feminist
and political economy perspectives suggests that
systemic biases explain observed differences in
how resources are allocated to men and women,
regardless of age. In other words, apparent gen-
der differences are the consequence of a male-
centered societal bias rather than actual gender
differences in need or age.15–17 Research by Bick-
nell and colleagues 18 supports this latter view, in-
dicating that women receive a substantially
higher proportion of services that are considered
appropriate, suggesting that some men may be
overtreated.
Within this framework, we explore differences
in Medicare expenditures for and utilization of
hospital, outpatient, skilled nursing facility, hos-
pice, home health, and physicians’ services by
gender and age.
METHODS
Data
For the preliminary study presented here, we
analyzed a 0.1% sample of all Medicare claims for
the years 1993–1998, drawn randomly from the
Medicare Standard Analytic Files (SAFs). These
files provide complete claims and enrollment
data on a random sample of beneficiaries with
claims in the target years. Individuals were se-
lected based on the terminal digits of their Social
Security numbers, with the same beneficiaries
falling into the sample each year.
 MEDICARE BENEFICIARIES AND HEALTH CARE USE 707

TABLE 1. SAMPLE CHARACTERISTICS (n 5 6967) 1998 (to identify data for the 12 months prior to
death, because the claims data date from January
Men Women 1, 1993 to December 31, 1998). The total sample for
n % n % analysis is 6,967 Medicare decedents.

Age groups Measures

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65–69 346 11.4 255 6.5

70–74 653 21.4 542 13.8 Outcome Variables:
75–79 667 21.9 710 18.1
80–84 678 22.3 880 22.4 Medicare expenditures. Total Medicare expen-
851 701 23.0 1535 39.1 ditures for hospitalization, skilled nursing facili-
Total 3045 100.0 3922 100.0 ties (SNF), hospice, home health care, outpatient
care, and physician visits were calculated sepa-
rately by site of care for all care provided in the
last year of life. In addition, total expenditures for
all care were calculated by summing expendi-
tures across all sites of care. Expenditures within
Cohort each site of care include physician’s services de-
The analyses were restricted to Medicare fee- livered on site. Therefore, expenditures on physi-
for-service beneficiaries age 65 and older without cian’s services as we refer to them were for physi-
Journal of Palliative Medicine 2002.5:705-712.

end-stage renal disease (ESRD) who were enrolled
continuously in both Medicare Part A (Hospital In-
surance) and Part B (Supplemental Medical Insur-
ance) for 12 months prior to their death. Medicare
beneficiaries with ESRD were excluded because
this population has patterns of health services cost
and use that are different from those of the more
typical Medicare beneficiaries over age 65. We in-
cluded only fee-for-service Medicare beneficiaries,
because beneficiaries in managed care did not
have complete claims data. We selected a popula-
tion that was continuously enrolled in both
Medicare Parts A and B in order to avoid selection
bias. The population of interest includes those who
died between January 1, 1994 and December 31,
cian visits provided in an office setting. All
expenditures were normalized to 1997 dollars to
control for price differences from 1994–1998.
Service utilization. We examined service uti-
lization including hospitalization, SNF use, hos-
pice use, home health care use, outpatient visits,
and physician visits (in an office or clinic setting).
Service utilization was measured as any service
use in the last year of life.
Beneficiary Attributes:
Gender was measured as a dichotomous vari-
able. Age was coded in 5-year strata (65 to 69, 70
to 74, 75 to 79, 80 to 84, and 851).

Inpatient
85+ Outpatient
Physician
SNF
80-84 Home Health
Hospice

75-79 * p < 0.001

70-74

65-69

$0 $8,750 $17,500 $26,250 $35,000

FIG. 1. Average Medicare expenditures by age.

 708 BIRD ET AL.

TABLE 2. MEAN TOTAL SPENDING FOR RESULTS

MEDICARE BENEFICIARIES IN THE
LAST YEAR OF LIFE BY AGE AND GENDER
Women comprised 56.3% of decedents. Over-
Age Total Men Women p valuea all, 89.2% were white, 8.1% were African Ameri-
can, and 2.7% were classified as “other.” The av-
65–69 $30,903 $28,590 $34,041 0.06 erage age was 80.6 years (78.1 years for men and
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70–74 $30,218 $29,244 $31,392 0.26

75–79 $27,903 $26,776 $28,963 0.20 81.4 years for women). Only 8.6% of decedents
80–84 $25,705 $25,010 $26,241 0.36 were age 65 to 69, due both to lower mortality in
851 $18,177 $19,659 $17,500 0.02 this age group and the fact that most beneficia-
Total $24,946 $25,480 $24,532 0.16 ries do not have a full year of eligibility until age
p-valueb ,0.001 ,0.001 ,0.001
66. Table 1 shows the age distribution by gender.
a The p values reported refer to statistical tests per- As shown in Figure 1, total Medicare expendi-
formed to determine significant differences in average tures in the last year of life were lower for older
total spending by gender.
b The p values reported refer to statistical tests per- decedents (p , 0.001). Average total Medicare
formed to determine significant differences in average to- expenditures in the last year of life were 70%
tal spending by age overall and for men and women higher for decedents in the youngest age group
separately. (those aged 65 to 69) compared to those in the
oldest group, (those who were 85 or above) (Table
2). However, over all age groups combined, total
Journal of Palliative Medicine 2002.5:705-712.

spending did not differ by gender (Fig. 2). Inter-

Analysis
Gender differences in end-of-life care were
examined through bivariate descriptive analy-
ses. Bivariate tests of differences in Medicare ex-
penditures on and utilization of hospitals,
skilled nursing facilities, outpatient facilities,
hospice, home health care, and physicians’ ser-
vices were conducted by gender overall, age
overall, and by gender within 5-year age strata.
t Tests and analysis of variance (ANOVA) were
used to compare average expenditures and x2
tests were used to compare categorical vari-
ables. No corrections were made for multiple
comparisons.
estingly, expenditures were higher for men than
women among those 85 and above ($19,659 vs.
$17,500, p 5 0.02). In contrast, among decedents
age 65 to 69, expenditures appeared higher
among women, although the difference was mar-
ginally significant ($28,590 vs. $34,041, p 5 0.06).
Average Medicare expenditures on inpatient
and outpatient care were significantly higher
overall for men than women ($17,854 vs. $16,334
for inpatient care, p , 0.01; $2,475 vs. $1,947 for
outpatient care, p , 0.001; analyses not shown).
Average inpatient expenditures were twice as
high for those decedents in the youngest age
group (age 65 to 69) compared to those in the old-

Inpatient
Outpatient
Physician
Women

SNF
Home Health
Hospice

* p < 0.16 for

overall difference
Men

$0 $10,000 $20,000 $30,000

FIG. 2. Average Medicare expenditures by gender.

 MEDICARE BENEFICIARIES AND HEALTH CARE USE
est group (age 85 and above) ($23,313 vs. $11,143).
Outpatient expenditures on those decedents age
65 to 69 were two and half times that spent on
those age 85 and above ($3,428 vs. $1,341). As
with overall spending, inpatient and outpatient
expenditures were significantly higher among
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men for those decedents age 85 and above
($17,854 vs. $16,334, p , 0.01 and $1,629 vs.
$1,209, p , 0.001, respectively).
Medicare expenditures for physician services
did not differ by gender either overall or within
age strata. They were significantly lower for the
oldest decedents although the trend was uneven
(analyses not shown).
In contrast, Medicare expenditures for SNF
care were significantly higher for women than
men ($2,531 vs. $2,023, p , 0.001) and were sig-
nificantly higher for older decedents (p , 0.001).
Within age strata, expenditures differed signifi-
Journal of Palliative Medicine 2002.5:705-712.
cantly only for those who were age 75 to 79
($2,847 for women vs. $1,848 for men, p , 0.0001).
Expenditures had a tendency to be higher for
women among decedents age 65–69 ($1,640 vs.
$1,065, p 5 0.07).
Overall Medicare expenditures for home
health care were higher on average for women
than men ($2,384 vs. $1,980, p 5 0.04) and in-
creased with age up to the 80 to 84 age strata (p ,
0.01). Within age strata, expenditures were sig-
nificantly higher for women among decedents
age 65 to 69 ($2,179 vs. $1,375, p , 0.03) and age
75 to 79 ($2,847 vs. $1,848, p , 0.03).
****Inpatient
Outpatient
**Physician
24.2%
****SNF
32.5%
***Home Health
15.4%
Hospice
15.4%
0% 20%
** p < .05, *** p < .01, **** p < .001
FIG. 3.
709
Average expenditures on hospice care did not
differ significantly either by gender or age over-
all. In general we found higher expenditures
among Medicare beneficiaries ages 70 to 79 with
fewer expenditures for the younger and older age
groups. Significant differences by age were found
for hospice expenditures among women but not
men. Within the 75 to 79 age stratum, average
hospice expenditures were almost twice as high
for women than men ($1,340 for women vs. $676
for men, p , 0.01).
Figure 3 compares the proportion of men and
women with any use of each type of health care
service in the last year of life. Overall, a higher
proportion of women than men used any inpa-
tient care in the last year of life (87.2% vs. 82.8%,
p , 0.0001). A higher proportion of women also
had any use of physician services (86.3% vs.
84.3%, p , 0.05), SNF care (32.5% vs. 24.2%, p ,
0.0001), and home health care (41.6% vs. 37.8%,
p , 0.01).
As shown in Table 3 and Figure 4, the overall
proportion of Medicare beneficiaries with any use
of services in the last year of life varied across age
groups for each of the services. The differences
across age groups were relatively small for inpa-
tient care, outpatient care, physician visits, and
home health care, but were slightly higher for
older decedents. However for outpatient care,
physician visits and home health care, service use
was lower for those age 85 and over than for those
ages 80 to 84.
82.8%
87.2%
94.7%
95.7%
84.3%
86.3%
Men
37.8%
Women
41.6%
40% 60% 80% 100%
Any use of services by gender.
 710 BIRD ET AL.

TABLE 3. ANY USE OF SERVICES BY AGE AND GENDER (ALL RESULTS IN PERCENTAGES )

Age Inpatient Outpatient Physician SNF Home health Hospice

65–69 Overalla 82.9*** 94.7*** 85.7*** 22.6**** 40.1**** 18.6****

Menb 79.5*** 92.2*** 83.8 19.7** 35.6*** 17.3
Women 87.5 98.0 88.2 26.7 46.3 20.4
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70–74 Overall 83.6 95.2 85.4 26.5 40.1 17.8

Men 81.3** 93.7*** 83.3** 21.3**** 36.3*** 17.3
Women 86.4 97.1 88.0 32.8 44.7 18.5

75–79 Overall 83.3 95.6 86.2 34.5 41.9 17.1

Men 80.1*** 94.9 83.8** 27.6**** 36.7**** 14.7**
Women 86.3 96.2 88.5 41.0 46.8 19.3

80–84 Overall 86.9 96.9 88.3 43.4 43.5 15.4

Men 85.6 96.2 88.5 39.2** 42.0 15.3
Women 88.0 97.5 88.2 46.6 44.7 15.5

851 Overall 86.9 94.1 82.9 53.4 36.1 12.3

Men 85.7 95.3 82.0 47.5**** 37.2 13.4
Women 87.4 93.6 83.3 56.1 35.5 11.7
Journal of Palliative Medicine 2002.5:705-712.

a Thep values reported refer to statistical tests performed to determine significant differences in service use by age.
b The
p values reported refer to statistical tests performed to determine significant differences in service use by gen-
der within age strata.
**p , 0.05, ***p , 0.01, ****p , 0.001.

In contrast to all other types of service use, the
gender difference in SNF care tended to be larger
in the older groups. As one would expect, SNF
use was substantially higher for older age groups.
However, the pattern of hospice use was re-
versed. Older decedents were less likely than
younger ones to have used hospice in their last
year of life (p , 0.001), though, as reported above,
the average hospice payment did not have an as-
sociation with age.
Table 3 shows utilization of services by age and
gender. With few exceptions among decedents
age 65 to 79 within each age strata, a higher pro-
portion of women than men had any use in the
last year of life for each of the health care services
examined. In contrast, among decedents age 80
and above, the only significant gender difference
in utilization was for SNF care. At all ages women
were substantially more likely to have used SNF
care in the last year of life.
DISCUSSION
Although prior research demonstrates gender
differences in health care, these preliminary
analyses suggest that having universal health
coverage through the Medicare program and be-
ing in the last year of life may act as an equalizer
for men’s and women’s experience with the
health care system. Previous studies have not fo-
cused on men’s and women’s care in the last year
of life. Moreover, few studies have examined
samples sufficiently large to address the con-
founding of age and gender.
Medicare spending in the last year of life is
strongly associated with age, rather than gender.
Our age-specific analyses showed that total
Medicare expenditures were 70% higher for the
youngest decedents, those who were age 65 to 69
than for the oldest, who were age 85 and above.
Indeed, overall Medicare expenditures did not
differ by gender. However, Medicare expendi-
tures for SNF and home health care in the last
year of life were higher for women than men and
expenditures for inpatient and outpatient care
were higher for men.
Age was significantly associated with having
used each of the six types of services examined.
Although the proportion with any use of SNF
care in the last year of life increased substantially
with age, use varied little by age for inpatient
care, outpatient care, physician visits, and home
health care.
If our data were split into “social supportive
services” (including SNF care, home health care
 MEDICARE BENEFICIARIES AND HEALTH CARE USE
***Inpatient
***Outpatient
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***Physician
****SNF
****Home Health
****Hospice
0% 20%
** p < .05, *** p < .01, **** p < .001
FIG. 4.
Journal of Palliative Medicine 2002.5:705-712.
and hospice care) and “acute care services” (in-
cluding inpatient care, outpatient care, and physi-
cian services), an interesting pattern emerges. On
average, expenditures were higher for women for
social supportive services in the last year of life.
Although women were more likely to have had
any utilization of inpatient and physician services
and as likely as men to have had outpatient care,
expenditures for men were higher on average for
acute care services in the last year of life.
Within age strata, relatively small gender dif-
ferences remain. This finding supports the argu-
ment that observed gender differences in end-of-
life care are in large part a function of women’s
greater longevity and the tendency to treat older
adults with less aggressive acute care and more
extensive social support services. However, the
overall pattern of those differences indicates a
tendency to treat men more aggressively among
the oldest decedents and treat women less ag-
gressively and more supportively, with an em-
phasis on services such as hospice even among
the youngest decedents. Our analyses help to de-
termine to what extent gender differences in
health care utilization at the end of life are be-
cause of women’s greater longevity or the ten-
dency to offer less aggressive care to the very old.
To the extent that we found gender differences
within age strata, those differences may arise
from variation in need for care or in treatment by
gender. Further research is necessary to examine
711
85+
80-84
75-79
70-74
65-69
40% 60% 80% 100%
Any use of services by age.
whether the differences reflect gender differences
in need not met by Medicare benefits or a ten-
dency to either undertreat older women or to
overtreat older men.
Our study is limited in two important ways.
First, these data lack information on marital sta-
tus, living situation, socioeconomic status, and
out-of-pocket expenditures, all of which would
allow us to explore the relations between health
care utilization and expenditures with other so-
cial and economic factors. Second, this sample
lacks the statistical power to conduct definitive
multivariate and time trend analyses, in part be-
cause the age strata reported here imply that age
should be operationalized in a nonlinear form.
Most of the change between age and expenditures
lies within a short span within the decade of 75
to 85 years, and that span may be conditioned by
a combination of gender and other characteris-
tics.
Future analyses will use a larger sample of
Medicare beneficiaries, which will allow us to
control for important covariates such as comor-
bidities and race, and to examine the extent to
which our findings may vary over time. Because
prior research conducted with data from earlier
periods has shown gender differences,4–6,11,18 fur-
ther analyses may suggest a time trend away
from gender disparities in care among Medicare
decedents.
We found that for Medicare eligible adults in
 712
their last year of life, gender was much less im-
portant than age in predicting utilization and ex-
penditures. This attenuation has not been found
in most other literature examining treatment for
particular conditions or cross sections of the pop-
ulation by age. In the last year of life, Medicare
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expenditures decline sharply with age but are not
particularly associated with gender within age
cohorts. Perhaps having Medicare insurance and
being sick enough to die combine to overcome
any general tendency to bias on the basis of gen-
der.
ACKNOWLEDGMENTS
Support for this paper was provided by a grant
from the Agency for Health Care Research and
Quality. This paper was presented at the Institute
Journal of Palliative Medicine 2002.5:705-712.
for Women’s Policy Research’s Annual Confer-
ence, Washington, D.C., June 8–9, 2001. The au-
thors wish to thank Tom Bell and Jeff McCartney
at Social and Scientific Systems, Inc. for their pro-
gramming and analysis support.
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Address reprint requests to:
Chloe Bird, Ph.D.
RAND
1700 Main Street
P.O. Box 2138
Santa Monica, CA 90407
E-mail: Chloe_Bird@rand.org