Controlling Costs Through Rationing End of Life Care

In the struggle to control health care costs, reported expenditures end of life expenditures often are a prime target for cost containment and cost cutting. While health care expenditures tend to significantly increase with age, American health care policymakers and citizens need to consider carefully the implications and advisability of rationing care based solely on the basis of age alone. 

It should not come as a surprise to anyone that the health care costs to care for young healthy people tend to be sigificantly lower than those required to care for  the elderly or disabled.  Health care expenditure statistics bear this out. For example, some studies reflect that the elderly (65 years of age and older) have consumed more than 33 percent of health care spending (Waldo, Sonnefeld, and Arnett 1989) and that their medical expenses are substantially higher in the last year of life (Scitovsky 1984; Riley et al. 1987; Scitovsky 1988; Gaumer and Stavins 1992; Temkin-Greener et al. 1992; Lubitz and Riley 1993; Scitovsky 1994; Barnato et al. 1999). While only 5 percent of elderly Medicare beneficiaries have died annually, the percentage of elderly Medicare expenditures spent on persons in the last year of life within the Medicare eligible population historically fluctuates between 27 percent and 31 percent (Lubitz and Riley 1993; Hogan et al. 2001). Mean annual Medicare expenditures for the last 12 months of life in the elderly.

With Medicare and other health care expenditures soaring as the Baby Boomer generation reaches retirement age, proposals to control costs by restricting health care expenditures to the elderly often appears a tempting solution.  However, Americans need to be careful about accepting and making decisions about the availability of care and resources for any particular resources in reliance upon retrospective reports of statistics not designed or appropriately tailored for predictive use. 

As aptly observed by Judy Hamilton in a insightful linkedin post, “The real problem is that you never know when the last six months are” until the person dies.  Consequently, studies of expenditures made after death inherently study individuals who have died.  Individuals who have lived typically are not part of the study. 

Consequently, predicting the life expectancy and outcome for a specific patient based on population outcome data drawn from a study of individuals who died typically is not very reliable for predicting whether a living person of a particular age in fact will live six months, six weeks, six hours, six minutes or six seconds.    

Second, merely averaging the dollars expended during the last six months of life for a generic population of individuals selected solely on the basis of their age-based Medicare eligibility and their death during the relevant six month measurement period provides little relevant insight into the quality or effectiveness of the care provided unless steps are properly taken to control and evaluate for factors such as the condition of the patient, education, genetics, income, care received, conditions and complicating factors suffered, access to care, attitudes of the patient and health care provider about the life, death and the value of care and many other factors among the individuals and groups of individuals in the study. 

Perhaps most significantly, even when controls are applied to account for relevant variations in the population studied, it is very difficulty to predict date of death with sufficient reliability to determine what the last six month of life are prospectively for any particular individual at any point of time unless actions are taken to effectuate or accellerate death at a predetermined time.  If Americans are going to make decisions based on the cost rather than the efficacy of care and the functionality of the life sustained, they should be honest with themselves and others about what they are doing. 

About Project COPE: The Coalition On Patient Empowerment & Its  Coalition on Responsible Health Policy

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of Project COPE

The Coalition for Responsible Health Policy

The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by not waiting for someone else to step up:  Speak up, step up and help bridge the gap when you or your organization can do so by extending yourself a little bit.  Speak up to help communicate and facilitate when you can.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining Project COPE: Coalition for Patient Empowerment here by sharing ideas, tools and other solutions and other resources. TheCoalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

Other Helpful Resources & Other Information

We hope that this information is useful to you.   If you found these updates of interest, you also be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, or our HR & Benefits Update electronic publication available here .  You also can access information about how you can arrange for training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail by creating or updating your profile here. You can access other recent updates and other informative publications and resources.

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