End of life care reportedly consumes a quarter of health care costs - (see the much quoted JAMA article from a decade ago).
Revisiting this issue because this week's NEJM has an article - NEJM -- Fighting On: Intercede about caring for a woman who's family wishes to push on with care, despite her wishes. As all of us on this blog know, these are one of the most painful situations as a provider to be in - navigating the treacheries of generations and subtleties of culture and tradition so that you can broker a frank discussion about death of a loved one. (as a side note, should the residents get first authorship here? give 'em a break!)
Ok, so what's the health policy angle here? Two quick ones that I see:
1- Health care costs DO NOT account for a majority of health care spend. If you look at the data since that JAMA article, you can see a decreasing amount of spend in end of life care. Current estimates are around 2% of costs are for end of life care. What's happened is that with the increasing prevalence of chronic diseases, and the overwhelming use of advanced medical techologies to manage chronic diseases, a greater and greater portion of health care costs are accrued in the outpatient setting - not at end of life, or in the inpatient setting, as many think. For further explanation see this McKinsey report, figure 2 which references Hogan et al, Health Affairs 2001, Riley and Lubitz, NEJM 1993, Strunk and Ginsburg, Health Affairs 2003.
2. The best way to reduce end of life costs (and to add dignity to death) is to have frank discussions with your loved one on goals of care BEFORE you or they get sick - if you look back at the JAMA article from above, that advanced directives can save between 25% to 40% of end of life costs. I'm sure the data has progressed since the publication of this paper, but still - it makes sound financial sense, and it's the right thing to do as a family. Having seen the turmoil that families go through when they haven't had these discussions, I can argue for cost savings up the wazoo, but in the end, it just adds dignity to death that we all deserve.
Thursday, January 29, 2009
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We should clarify what you mean by "end of life costs." When I looked at this, if you count end of life costs as all medical costs (inpatient, outpatient, drugs, etc) during the last six months of life, then they were a significant portion of that person's health care costs. It sounds like you may be talking about only the terminal admission?
ReplyDeletethat may be true - i'll look deeper into this. regardless, if the range is 2% - 25%, my working hypotheses is still that advanced directives are probably the best way to cut down on end of life care, and that outpatient costs account for more than drugs, long term care, end of life care, inpatient care, etc.
ReplyDeleteor i guess comparative effectiveness usage could cut down costs, but that would have system wide consequence, not just end of life care. and impact would likely be greater in the outpatient setting.