Comparison of Health Care Cost Trajectories in the Last Year of Life by Age at Death

Importance End-of-life (EOL) costs account for a disproportionately large share of total Medicare expenditures. However, there is a lack of research examining EOL costs of patients in the US across the full spectrum of ages. Objective To report EOL costs and the monthly health care cost trajectory in the year before death across age groups in the US. Design, Setting, and Participants This cohort study included individuals aged 0 to 75 years or older identified from the MarketScan Mortality Detail file who died from January 2016 to December 2024. Data were linked to the MarketScan Commercial Claims and Encounters and MarketScan Medicare databases. Exposure Age at death, categorized as 18 years or younger, 19 to 49 years, 50 to 64 years, 65 to 74 years, or 75 years or older. Main Outcomes and Measures Total and out-of-pocket (OOP) health care costs (in 2025 US dollars) in the 365 days before the date of death for patients who died in a hospital and in the month of death and the 11 months prior for patients who did not die in a hospital. Both actual and standardized (ie, Medicare pricing) costs were determined. A generalized linear model with γ family and log link and quantile regression were applied to compare mean and median costs, respectively, across age groups. Results Among 313 649 individuals who died from 2016 to 2024 (51.1% male; mean [SD] age at death, 77.5 [14.3] years), median actual EOL costs from the unadjusted analysis were $50 599 (IQR, $21 258-$109 121) overall; the adjusted actual median costs were highest for the youngest age group (≤18 years; $165 030 [95% CI, $160 110-$169 951]) followed by the group aged 50 to 64 years ($132 542 [95% CI, $131 698-$133 386]) and were lowest in the oldest age group (≥75 years; $48 308 [95% CI, $47 945-$48 671]). After standardizing costs to Medicare pricing, adjusted median EOL costs were $49 259 (IQR, $20 889-$103 317) overall and were highest in the youngest age group (≤18 years; $104 386 [95% CI, $100 144-$108 628]) followed by the group aged 50 to 64 years ($99 182 [95% CI, $98 454-$99 909]), with the lowest median costs observed in the oldest age group (≥75 years, $48 308 [95% CI, $47 945-$48 671]). Unadjusted OOP costs were also higher in younger age groups: 18 years or younger, $4274 (IQR, $1979-$6713); 19 to 49 years, $4063 (IQR, $1640-$6638); 50 to 64 years, $4048 (IQR, $1954-$6556); 65 to 74 years, $1793 (IQR, $1081-$2580); 75 years or older, $1509 (IQR, $793-$2299). Monthly cost trajectories showed EOL costs were persistently higher in younger age groups, with the sharpest increase within 3 months of death and peaking in the month of death (eg, mean total cost of $220 819 [95% CI, $195 716-$245 923] in the last month for patients aged ≤18 years). A much higher percentage of the youngest group (82.3%) died in a hospital compared with the oldest group (20.8%). Conclusions In this cohort study of EOL costs across age groups, total and OOP costs were substantially higher in patients younger than 65 years vs 65 years or older, even after standardizing to Medicare pricing. Death in a hospital was more common in the younger age groups. The findings suggest attention to EOL care should be expanded beyond Medicare beneficiaries to patients who die young.