Older adults with disability who lack adequate support in the community are likelier to have higher Medicare spending, according to study results recently published in the Annals of Internal Medicine. This underscores the potential decrease in healthcare spending associated with community support and services.

This observational study included 3716 adults aged ≥65 years and living in communities, all of whom used fee-for-service Medicare and who were alive ≥12 months after their interview. Of these participants, 1877 were selected for subanalysis according to having ≥1 activity limitation. Participants were asked about performing daily activities with a 1-month recall period, including household activities, mobility, and self-care. Participants reported on whether they received help with the activity and how difficult it was, as well as whether any negative consequences arose from not receiving help. The primary outcome of the study was the total amount spent on Medicare for reimbursed services within 1 year after the interview. Using multivariable regression models with adjustments for individual characteristics, spending was stratified by quartiles.

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Approximately a quarter (25.6%) of participants with mobility disability, 20% with self-care disability, and 18.3% with household activity disability reported negative consequences. Among the most commonly reported negative consequences were soiling/wetting while using the toilet (39.3%), being confined to the indoors (27.9%), having restricted mobility within one’s home (24.3%), and incorrectly taking prescribed medicines (22%). Participants who reported negative consequences had higher median Medicare spending than participants who reported none, with $4866 vs $4095 for participants with household disability, $7266 vs $4155 for mobility disability, and $10,995 vs $4436 for self-care disability.

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Participants with negative consequences in household activities did not show significantly different median spending in analyses adjusted for regression ($338 [95% CI, −$768 to $1444]); however, such analyses did reveal higher median spending for participants with self-care ($3187 [95% CI, $432-$5942]) and mobility disability ($2309 [95% CI, $208-$4409]). Participants with self-care disability showed an association between negative consequences and $1460 (95% CI, $358-$2561) of additional spending in the 25th percentile. There were no statistically significant differences among the highest quartile.

Limitations to this study include a lack of generalizability to certain Medicare beneficiaries, a restriction to total Medicare spending, a lack of investigation into services paid for by other payers or out-of-pocket, and a lack of causal inference.

The study researchers concluded that “Medicare spending is higher among older adults with disability who live in the community and lack adequate support. The results suggest that the beneficial effects of comprehensive community-based, long-term services and support may extend beyond improved health, well-being, and participation to reduced spending on health services and that efforts to address costs and quality of care may benefit from strategies that target both health and function.”


Wolff JL, Nicholas LH, Willink A, Mulcahy J, Davis K, Kasper JD. Medicare spending and the adequacy of support with daily activities in community-living older adults with disability: an observational study [published online May 28, 2019]. Ann Intern Med. doi:10.7326/M18-2467