Health Care Costs and Choices in the Last Years of Life

March 03 01:00 2015 by ushadmin

Many U.S. patients endure pointless treatments because their doctors don’t know how to talk about death. But that’s changing as hospice and palliative care are gaining ground.

As a Scottish-Canadian-Californian, I have always said that I have a unique perspective on health care and all things to do with health care, including death and dying: The Scots see death as imminent. Canadians see death as inevitable. And Californians see death as optional.
I wrote that joke more than 20 years ago and continue to use it because it tells a fundamental truth: that Americans and the American health care system are uncomfortable with the inevitability of mortality.

Patients and families consistently report preferences to die peacefully at home, but all too often we die in hospitals with a highly medicalized and uncomfortable end. This column will explore the economic and societal issues of end-of-life care for an aging society. How does the United States rate versus other countries, and what are the opportunities for hospitals and health systems to improve care at the end of life?

Care and Costs in the Very Old

Let’s start with a fact base. We are all going to die. And the chances are that more of us will die at an older age. By 2050, the number of people on Medicare who are 80 and older will nearly triple; the number of people in their 90s and 100s will quadruple.

Recent analysis of Medicare claims data (excluding Medicare Advantage enrollees) conducted by the Kaiser Family Foundation found that Medicare spending rises with age and peaks at 96, declining slightly at older ages. Spending at age 96 is $16,145, more than double the per capita spending at age 70 ($7,566). Even excluding those who died in the given year, the pattern persists. Interestingly, the peak age of spending varies with the Medicare service line; for example, inpatient per capita spending peaks at age 89, Part B and D drugs at 83 and outpatient at 83. Services such as hospice peak at 104 years of age, skilled nursing facilities at 98 and home health at 96.

We are living longer and consuming services at an increasingly intense rate well into our 90s. And this Kaiser Family Foundation analysis, by its own admission, underestimates the health care costs of the very old, because it does not include Medicaid, the principle payer for nursing home expenses.

Indeed, the Centers for Medicare & Medicaid Services develops estimates of age-specific cost estimates for all expenditures for all payers. The estimates show that between 2002 and 2010, per capita spending for those 65 to 84 years old grew 36 percent from $11,692 per capita to $15,857 per capita, while per capita spending for those older than 85 grew by 38 percent from $25,192 to $34,783 over the same period. This reflects a pattern of rising age-specific utilization rates that has been documented in many countries including the United States: Over time, we treat older generations more intensely.