Hemlock Society & Foundation of Florida

Cost of health care late in life can vary widely

By Mario Garrett

Reprinted from San Diego Union-Tribune, Tuesday, November 23, 2010

During the five-year period 2001-05, nearly a third of total Medicare spending went toward the care of dying patients during their last two years of life, which translates to $140 billion. Eli Ginzberg, the noted economist, has called it, “the high cost of dying.”

Medical care costs peak at the end of life. An implied assumption is that the high medical expenses at the end of life are due largely to aggressive, intensive, expensive, and high-technology interventions for some patients who are dying. Contrary to this popular belief, data show that the number of patients with very high medical expenses is quite small.

Geography can help us understand the variability in health care costs, and why. The highest-spending states consumed more than 1½ times the Medicare dollars spent by the lowest-spending states. If you examine total Medicare spending during the last two years of life for patients with at least one of nine chronic conditions, three states — New Jersey ($59,379 per person), California ($57,914 per person), and New York ($55,718 per person) — spent at a level more than 20 percent above the national average of $46,412 per person. As an extreme case, Hahnemann University Hospital-Philadelphia, spent an average of $117,998 per dying patient during the last two years of life.

A recent study in California — one of those expensive states — has reported that between 1999-2003, Medicare patients in Los Angeles made 2.3 times more visits to specialists than did comparable patients in Sacramento. They also spent twice as many days in intensive care and were hospitalized 1.6 times longer. The argument is that if facilities and services exist, everyone, including dying patients, gets to use them. This is known as supply-driven demand — if you have it, they will come. The projected Medicare expenditure for the remaining life of a 65-year-old in Los Angeles is $84,000 greater than for a 65-year-old in Seattle.

Despite the fact that Los Angeles has a greater number of specialists and hospital beds per person than most regions of the state, hospitals in Los Angeles were less likely to provide proper care for patients suffering from heart disease, congestive heart failure, or pneumonia than were hospitals in the far less expensive Sacramento region. Los Angeles-region hospitals also ranked lower on patient satisfaction surveys.

Supply-driven demand assumes the patient wants the treatments being offered. But it is becoming increasingly likely (as seen in advance directives, and do-not-resuscitate directives) that patients do not want invasive treatments and other procedures. It is also becoming more likely, because of the increasing rate of dementia, that dying patients might not be competent to assert their wishes.

We need to better communicate our wishes of how we want to die. One of the precepts in the Dying Patient’s Bill of Rights, as published in the American Journal of Nursing, is the right to die in peace and dignity. People who make the choice to opt out of treatment need to communicate this. It is only then can we truly express the fundamental right of patient autonomy — our choice of how we die.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com


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