End of life savings will likely disappoint, ctd.

Several people have asked for more basic information about health care costs at the end of life which I will provide over several posts. Brenda Spillman and James Lubitz have done some of the classic work (a bit dated, but a model for clarity) on the relationship between age at death and cost. The first figure shows the relationship between age at death and costs in the last 2 years of life (1996 dollars). Basically, Medicare costs get lower the older a person experiences death, while nursing home costs get higher, with total costs rising with older age at death.

Note the time frame is last 2 years of life, so is more telescoped forward from death than many end of life studies, but the retrospective nature of the identification is the same.

The second figure shows cumulative costs from age 65 until death, by age at death (1996 dollars). Of course cumulative costs rise with older age at death since persons were at “risk” of health care expenditures for a longer period of time. Cumulative costs are slightly higher for women than men by age of death (fig. 3 in the paper; not shown here) which is an effect separate from a gender-specific survival difference. The authors speculate this to be because diseases progress to death faster in men than women, and it is likely exacerbated by the increased chance that a wife outlives her husband.

These are high level descriptions of the relationship between cost and the age at death. The increase in nursing home costs in the two years prior to death with older death age is easy to explain; older age leads to increased disability and an increased chance of outliving your spouse which increases the risk of institutionalization.

The decrease in the Medicare cost the last 2 years of life with older age at death is a bit trickier to explain. This phenomenon coexists with the general finding that 1 in 4 Medicare dollars are spent in the last year of someones life; but the declining Medicare cost in the last two years of life with older age at death suggests there is a moderation of expenditure the older a person gets. In other words, if this phenomenon didn’t exist, the accumulation of costs relatively near death would be even greater in the Medicare program.

What cannot be answered by analyses such as this one (or really any claims based approach) are whether such decreases in the propensity to spend with older age at death are driven by explicit wishes of patients, or more implicit decisions/interactions between patients, family members and providers throughout the health care system. These are key questions.

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Brenda C. Spillman and James Lubitz. New England Journal of Medicine 2000; 342:1409-1415

End of Life conversation

Consider the Conversation is a documentary about end of life care. There is a great deal of buzz in the hospice and palliative care communities about this film because of its joining of expert perspective with patient stories that have not been ‘sugar coated’. Here is a review of the film at Pallimed, a great hospice and palliative medicine blog.

There is a great deal of heat but little light in the way in which we talk about end of life issues. Many people are swayed by the rhetoric of death panels and such because talking about death is still a taboo subject. So, we are not good at it. And it is scary. A great deal of my current research focuses on hospice, palliative care and patient decision making at the end of life.

I got interested in this general topic because of a personal experience, helping my wife’s Aunt who was dying from Cancer about 15 years ago. She asked me to help her make some practical decisions because she had minor children and was unmarried as she approached death. I became her researcher, and looked into everything from treatment options for her Cancer to finding and arranging for the least expensive way for her to be cremated. It was much more difficult than I thought it would be, in large part because even though I thought she was very clear about her wishes, as her health failed there always seemed to be circumstances that were unforeseen. There were times I wished we had talked more, and more explicitly. And there were a lot of people involved, who didn’t always agree on what to do. Complicated stuff.

The experience of being involved in this situation has changed the way I think about health policy, and indeed how I teach my Intro to the U.S. Health Care System course. Now I begin this course with the only thing I know for certain to be 100% true on the first day:

  • Everyone will die, it is only a matter of when and from what (we then walk through detailed mortality rate tables)

If it is true that everyone dies (and it is), this means that eventually care designed to forestall the inevitable will at some point become non productive (it won’t work anymore). This should be uncontroversial, but it is not. Open discussion of these realities remains a taboo. I am not telling you what to conclude about how we should/you wish to face these realities. However, I am telling you we need to think and talk about them.