The Cost and Quality Conundrum of American End-of-Life Care

What’s the Cost?

End of life care costs is a problem for Medicare. Most people dying in America are older Medicare recipients. This has produced a program grappling with economic sustainability. Medicare spending on a normal beneficiary pales compared to the cost at the end of life. Some specialists think that over 25 percent of Medicare spending is going towards the 5 percent of recipients who pass away annually.

It isn’t a shock that Medicare puts more money out for beneficiaries in their last year of life. That’s the period when medical attention is in greatest need. Inpatient hospital stays, physician services, and skilled nursing facilities help ratchet up the costs.

Of the entire end of life period, the last month of life is especially expensive. Medicare spends an average of over $6,600 just during the last 30-days of a beneficiary’s life. The dramatic increases are driven by inpatient hospital stays and related costs.

Too Much Care?

An increase in medical care is expected at the end of life. Proactive approaches at the end of life has been steadily increasing, and there are no signs of it slowing down. Riley and Lubitz found that the percentage of decedents experiencing multiple hospitalizations increase from 20 percent in 1978 to 27 percent in 2006 while the proportion of ICU services in the last 60-90 days of life rose from over 25 percent to almost 34 percent in the same timeframe.

While the merits of aggressive treatment have been discussed, most experts believe that the use of intensive services at the closure of life has little clinical benefit to their patient. Dr. Atul Gawande’s article, “Letting Go,” shows the heartrending effects of confusion and discomfort during which could otherwise be a peaceful experience.

Gawande’s article tells about the health care of Sara Monopi, a young woman, with melanoma, who went through three bouts of chemotherapy, radiation, many hospitalizations and two experimental treatments — despite her physicians knowing her infirmity was not curable. Sara ultimately died, but only after experiencing expensive and unnecessary treatment. Gawande wrote, “Almost nothing we had done had any likely achieved something besides making her worse. She may have survived longer without it.”

Hospice physician, Dr. Joanne Lynn, terms the present approach to end-of-life care as wasteful. Lynn, Director of the Center for Elder Care at Altarum Institute, believes per-capita costs would go down if some hospitalizations and treatment plans were lessened.

“At the moment, there’s a blank check on Medicare-type expenses,” Lynn said. “We have people go through imaging studies, surgeries and repeated hospital visits. If we utilized services to meet people’s needs, we would use hospitalization less and would use high-cost interventions and diagnostic tests less as well.”

Lynn has research to support her statements. A 2009 Social Security Advisory Board advocates for a decreased in procedures that do not benefit patients. The report states that the research on costs and services show the government could achieve savings across the health spectrum by cutting down on the use of unnecessary medical services.

When Lynn began working in nursing homes in 1978, there were states where frail and elderly patients were still tied to their beds 24/7. Since then, America’s treatment of the old has improved.

With the baby boomer population aging, the consequent rising health care costs may break the bank for the nation’s long-term health care system.

Planning for the End May Help Cut Costs

Research has shown that thinking ahead for end-of-life care through devices such as advance directives could reduce spending. Using advance directives which would specify end-of-life limitations often lead to lower Medicare spending in geographic regions that previously had high end-of-life costs.

Physicians need improved training on how to carry on discussions about end-of-life decision starting when the patient is healthy and young. The conversation should be focused so that the frame is on the quality of life and getting the consumer the type of care they want.

Providers should also engage in noting conversations with patients when they’re healthy. Knowing in advance how the patients want to receive health care can cut costs later in the final months of life.

Terry Berthelot, a senior lawyer with the Center for Medicare Advocacy, believes advance directives could be the “holy grail” of America’s end-of-life crisis.

“They could preserve  a vast deal of money because presently people are getting all types of end-of-life care that are expensive and doesn’t save lives. It only prolongs life at a huge cost with no benefit,” she said.

Could Hospice be the answer

Hospice care helps people live longer, Berthelot says. “A part of that is the fact that they aren’t bouncing between home and the hospital and the skilled nursing facility.”

There is an increase in access to hospice care. Medicare beneficiaries’ use of hospice services nearly doubled between 2000 and 20110. MedPAC reports that 45 percent of beneficiaries who died that year used hospice and that reflects an increase of just under 24 percent in 2000.

The average hospice stay hasn’t changed significantly, though. Harvard Med School professor David Stevenson said in a 2012 article in The New England Journal of Medicine. The average stay rose from 17 days in 2000 to 18 in 2010. Steven wrote the slight change reflects the fact that a significant minority of beneficiaries go into hospice care just days before their deaths.

The group that hospice care helps has changed since the start of the Medicare benefit which provides the service. In 1990, 16 percent of hospice care (Medicare) recipients had non-cancer diagnoses. By November 2012, it was over 66 percent.

Lynn says hospice is a portion of the answer to America’s healthcare system’s end-of-life health care issues. Lynn believes it is imperative that the nation find a way and perform the answer to the end-of-life care model’s concerns, or Americans will confront a choice between bankrupting themselves or rejecting the elderly.