End-of-Life Care Costs Under Scrutiny

According to the most recent report from an ongoing national study of health care, there is too much waste and not enough price consistency in medical care in the last months of life. To many care providers and to a public faced with ever-increasing medical bills, the situation leads to important policy and ethical questions. Is the US financial "investment" in the chronically ill and those near death really excessive? Couldn't some of those dollars be put to better use elsewhere in the health care system?

The Dartmouth Atlas of Health Care studies have played a significant role in raising and often answering those types of questions for more than 12 years. The newest data and analyses, by the Dartmouth College Medical School Center for the Evaluative Clinical Sciences, was released in May 2006 and showed a wide variation in end-of-life costs between provider systems and between individual hospitals.

At one medical center in Milwaukee, for example, a patient in the final two years of life spent about 40% more days in the hospital and received about 40% more physician visits than the statewide average. Across the US, the data shows that more services, treatments, hospital stays, and doctor visits don't generally translate into improved quality of care.

"There is a combination of social forces, health care forces, and health system forces that all lead doctors to do too many tests and offer too many useless treatments near the end of life," said David E. Weissman, MD, FACP, Medical College of Wisconsin Professor of Medicine and Director of the Palliative Care Center of Froedtert & The Medical College. "Our societal ethic that says 'we win wars,' 'we fight wars on cancer,' and 'it's weak to give up,' along with doctors' fears of malpractice and their fears of not doing everything possible, all contribute to over-treatment near the end of life.

"One of the reasons that the palliative care movement began in the 1990s was to help patients, families and doctors to recognize when it was time to move away from further life-prolonging treatments that really would offer little to no benefit," Dr. Weissman said. "Many hospitals around the country have been able to demonstrate substantial cost savings due to a reduction of unnecessary tests and treatment. This doesn't mean a reduction in caring or in providing optimal care. What it means is avoiding tests and treatments that are really only done for reasons that have nothing to do with making the patient get better.

"We're not yet really 'incentivized' to provide cost-efficient compassionate care," he continued. "Current payers seem very willing to pay for patients in the hospital as long as we're doing CAT scans, MRIs, and other tests. But the moment I tell them a patient is dying, they want the patient out. The incentive is for us to keep doing tests and procedures. It's not about providing the best level of care."

Unnecessary Spending Abounds
The records of about 4.7 million Medicare patients who died between 2000 and 2003 were studied in the new Dartmouth research. The patients all had one or more of 12 chronic diseases, including cancer or heart, lung, or kidney conditions. It was estimated that almost one-third of the Medicare spending on those patients did not improve health and was therefore termed "unnecessary."

"Unacceptable variations" in the cost of health care from provider system to provider system were also found in abundance in the most recent study. In one example, it was shown that hospital and physician costs in Utah would each be about one-third lower if all health systems in that state operated in the manner of the most efficient Utah system.

Other recent Dartmouth studies have shown that regions with the highest health care costs actually have lower-than-average outcomes and poorer quality of care in general. With about three-quarters of total US health care costs resulting from treating the chronically ill, some may argue that we needlessly sacrifice resources on end-of-life cases that could be applied to those with the chance of brighter outcomes.

"We're not making that kind of tradeoff in the US because we don't operate in a closed health care system, where there is a fixed number of dollars for health care, and thus the need to choose how to allocate those dollars," said Dr. Weissman. "Our health care system is open-ended, which is why the cost of health care goes up every year. So we're not making a tradeoff of spending more on the elderly and thus not using those resources on children's care.

"I do buy the argument that the cost of care, particularly toward the end of life, is far higher than it needs to be. We know from the national data that there are wide discrepancies in how much is spent on health care, with no difference in outcomes. So there is clearly a problem in the system."

Lower Costs a Societal Matter
During the recent Dartmouth study period, Medicare spending in the last two years of life averaged $25,343 per patient in Wisconsin, lower than the national average of $29,199 and much lower than the $39,810 spent in the highest-cost state, New Jersey.

"A tenet of medical care in the United States in providing good, ethical medical care is that you don't base cost decisions on individual patients," said Dr. Weissman. "Issues around cost have to be decided at a societal level, whether through legislation, regulations, or community policy decisions on how we want to spend our health care dollars. But we don't make those decisions on an individual patient basis."

Dr. Weissman said that several more years may pass before enough pressure is brought to bear on the political process to compel major changes in how health care costs are managed. "Our health care system in the last 50 years has gotten increasingly complicated and increasingly out of control," he said.

"The path to change must be political, and it will likely emerge from the world of business, as health care costs are having a major impact on Americans' ability to compete in the international marketplace. Without predicting what shape a new system would be, it would have to involve changing the system of incentives."

Dan Ullrich
HealthLink Contributing Writer

The Palliative Care Center is part of the Froedtert & The Medical College of Wisconsin Neoplastic Diseases and Related Disorders Clinic.

For more information on this topic, see Dr. Weissman's HealthLink article End-of-Life Care Eases Pain and Prepares Patient for Death.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.