4/29/2011 7:27 PM ET|
The high cost of dying
The rising price of end-of-life care threatens family savings and complicates efforts to reduce the federal budget.
Medical science is getting better at prolonging life, even for the sickest of patients. What hasn't been so successful is reining in the cost of all that extra care.
Financing end-of-life care is getting harder as 80 million baby boomers start to reach retirement age. That spells trouble for family savings and efforts to reduce the federal budget.
Federal health-care spending is currently about 8% of gross domestic product. The Government Accountability Office predicts that amount, unchecked, could almost double over the next 40 years. More than $50 billion a year is estimated to be paid out by Medicare each year for patients in their final two months of life.
The controversial budget plan proposed by Rep. Paul Ryan, R-Wis., would scrap Medicare and instead issue health-care vouchers for seniors in an effort to cut spending. Other measures to reduce Medicare costs were included in the health-care-reform package that became law last year, including incentives for patient-doctor end-of-life counseling that were derided by partisan critics as "death panels."
Aggressive care -- at a cost
Chronically ill Medicare patients spent fewer days in the hospital and received more hospice care in 2007 than they did in 2003, but at the same time there was an increase in the intensity of care for patients who were hospitalized, according to a study on end-of-life care released April 12 by the Dartmouth Atlas Project, a research effort by Dartmouth University. Despite that shift, those patients had significantly more visits from physicians, particularly medical specialists, and spent more days in intensive-care units.
"In addition to its effects on patients' quality of life, unnecessarily aggressive care carries a high financial cost," says Dr. David Goodman, lead author of the study and director of the Center for Health Policy Research at Dartmouth's Institute for Health Policy and Clinical Practice. "About one-fourth of all Medicare spending goes to pay for the care of patients in their last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease."
From 2003 to 2007, the share of chronically ill patients dying in hospitals declined in most regions. In 2007, the highest rates of death in a hospital were in regions in and around New York City, including Manhattan, 46%; East Long Island, 42%; and the Bronx, 40%. Chronically ill patients were far less likely to die in a hospital in Fort Lauderdale, Fla., 19%; and Portland, Ore., 20%.
In 2007, chronically ill patients in Manhattan, however, spent on average 20.6 days in the hospital during those final months, almost four times more than patients in Ogden, Utah, where the average was 5.2 days. The national average was 10.9 days per patient.
Most Medicare patients in many parts of the country are cared for by 10 or more doctors in their final days, according to the research.
The sort of end-of-life counseling proposed as part of health-care reform factors into the findings.
"It may be possible to reduce spending, while also improving the quality of care, by ensuring that patient preferences are more closely followed," Goodman says. This includes giving chronically ill people hospice and home-care options, and empowering them to dictate terms for life support and resuscitation.
Research on Medicare spending by the Boston University School of Medicine and the National Institutes of Health, published in the Archives of Internal Medicine, found that blacks and Hispanics are significantly more likely than whites to be admitted to an intensive-care unit in their final six months of life and accrue higher costs. Using 2001 data, the researchers found that in the final six months of life, costs for whites averaged $20,166; for blacks, $26,704 (32% more); and for Hispanics, $31,702 (57% more).
"Some studies have found minorities to be more reluctant than whites to have do-not-resuscitate orders, more likely to prefer life-sustaining treatments at the end of life, and less likely to use hospice," the authors say.
Drug costs also a factor
Drug costs are also driving up Medicare's burden.
Cost is not a consideration for what's covered. This is evident in the expensive drug regimens allowed, even if they are primarily used for older, often terminally ill patients and extend life for only months, not years.
The chemotherapy drug Avastin costs up to $55,000, despite adding only a few weeks of life for many terminally ill breast-cancer patients. By this summer, it is expected that the U.S. Centers for Medicare and Medicaid Services will approve coverage for Dendreon's Provenge for men with advanced prostate cancer. Though the drug has been touted as a vaccine, the Medicare proposal instead seeks to allow its use as a specialized immune-system booster at a cost that could exceed $93,000 for a complete regimen.
Financially, one's final days can eat up any nest egg that remains and often pass along costs to a family. Genworth Financial estimates that nursing-home care, nationally, averages about $75,190 a year. Health aides will cost at least $20 an hour if one cares for a dying relative in the home, in addition to thousands of dollars in other out-of-pocket expenses each year.
This article was reported by Joe Mont for TheStreet.
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I work in a hospital and watch the elderly die frequently. The problem isn't the elder but the family not knowing when to let go. The patient may be comatose or have been revived with
CPR several times (but never awake or aware) and the family continues to want "everything done." The poor elder lingers for days on a ventilator, hooked into many IV's, in a noisy, undignified ICU setting with no hope of recovery.
The daily costs are enormous. If the patient feels anything at all, it is pain. The doctor and hospital are forced to torture the patient to death since the family hasn't the courage to make a decision.
This is why end of life discussions and decisions about what the individual wants needs to occur BEFORE the family has to make the decision for the patient. This is what Obamacare was trying to allow. Discussions NOT decisions to terminate care but discussions about what the patient, himself, wants.
It is terrible to be responsible for saying "We need to stop and let mother go." Sometimes it is the only humane thing to do but still families cannot do it.
The problem occurs when the patient thinks "unnecessarily aggressive care" means "unnecessarily aggressive care," and the doctor/hospital thinks it means "doing anything that prolongs life or treats the condition." Please do not rely on vague terms with little or no legal teeth in your advance directive and expect everybody to interpret them as you would: spell it out like you are writing the Complete Idiot's Guide. Speaking of which, it's not empowering if the default option (as it often is) is to have everything removed and you have to opt in to not off yourself. It already sets you up as something of a troublemaker if you deviate.
The part about minorities smacks of pressure and irritation that they won't just die already. It is disgusting and has no place here. Then again, I keep asking myself why I'm surprised by anything anymore.
We have to help people accept the reality of the situation vs. the cost.
Chronically ill patients need to receive ongoing counseling to help them realize when enough is enough. It should not be the hospitals decision or the doctors decision.
As for minorities, we do not have a lot of faith in the medical profession. I know from personal experience that the profession does not listen to what we say and acts as if we can't possibly understand what they say to us. I was told by a doctor that black people do not know their own medical history, so when I told him of a drug allergy, he ignored what I said and prescribed a variation of the drug (I was allergic to this one too).
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