Cost Savings at the End of Life - can primary care make a difference?

I was recently asked to comment on what effect does "end of life" care have on the rise of health care costs in the US. probably the most relevant article that E. Emanuel (in White House currently) wrote a decade ago.

JAMA -- Abstract: Cost Savings at the End of Life: What Do the Data Show?, June 26, 1996, Emanuel 275 (24): 1907

My thoughts are below:

1) There is nothing inherently wrong with spending a majority of your money for inpatient care in the last years of life. The more appropriate questions are 1) is the percentage of money spent the right percentage of money overall spent and 2) is the rate of inflation for end of life costs in line or out of line with other expenditures.

When you look at the work that the McKinsey Global Institute did, we found that the major driver of health care cost inflation was outpatient delivery of care - not inpatient care.

2) Outpatient medicine accounts for more than 40 percent of overall health care spending and 68 percent of spending above expected compared to other OECD countries. This category expanded at 7.5 percent per annum from 2003 to 2006—a faster pace of growth than observed in any other cost category—to add more than $166 billion in costs during this period.

3) Inpatient care costs account for 25 percent of overall health care spending but only 6 percent of total spending above expected ($40 billion). This category grew by 6.0 percent annually (trailing GDP growth), or $73 billion, from 2003 to 2006.


End of life issues are tricky - they raise a lot of emotions. But if we look at this purely from a data perspective, the heart of the cost problem is in outpatient care. So yes, you could argue that there is an imperative to reform end of life care since they consume a majority of costs on the inpatient side. But the elderly (=Medicare) spend a large portion of their medical lives admitted in the hospital. And that's okay, in my opinion. If our goal is to bend the cost curve, we should focus on outpatient, not inpatient, care.

Can primary care help reduce the inpatient end of life care costs? I think so - I don't know the data as well. But my hypothesis would be that 1) people at end of life do not make rational informed choices about the care they wish to receive (living wills, care directives, durable power of attorney) and thus 2) they receive more care than they would have wished, but they are too sick to express their views (e.g. stroke patient on life support who would not have wanted to have been on life support). If primary care could provide greater information about what options are available at end of life, people could make more informed decisions. This is what the whole "death panel" issue was about. If these policies could be promoted in a way that ensures a means for patients to exercise their autonomy on end of life issues and are not coerced, then to me this obviously makes sense.