I wrote: <snipped nearly all> > I fear I forget the exact figures, but something like > 60-75% of healthcare costs occur in the last months > of a person's life, and I'm guessing that at least >30% of that is futile. >[I'll see if I can find some proper figures.]
Finding accurate figures is going to be more problematic than I thought, as while there are good numbers for government programs, private outlay is less well-documented. But the numbers above are too high. http://www.ahrq.gov/research/apr03/0403RA25.htm "...The mean annual medical expenditures (1996 dollars) for the elderly from 1992 to 1996 were $37,581 during the last year of life versus $7,365 for other years. The estimated 1992-1996 mean Medicare expenses during the last year of life were $22,967. However, the portion of Medicare expenses spent on the last year of life in 1992-1996 was 26 percent, similar to that spent on the last year of life between 1976 and 1988..." On overall expenditures (a 1997 article): http://www.nap.edu/openbook/0309063728/html/154.html "The United States has experienced years of mounting concern about steep increases in health care spending and in the share of national resources devoted to health care. Between 1970 and 1994, personal health care spending grew from $63.8 billion to $831.7 billion (from $310.9 to $764.6 billion in 1992 dollars), and the percentage of the U.S. gross domestic product devoted to health care rose from 7.1 percent to 13.7 percent (Levit et al., 1996)..." Medicare figures: http://www.ahrq.gov/research/sep01/901RA16.htm About one-fourth (27 percent) of Medicare costs are for the last year of life, unchanged from 20 years ago. These high costs reflect care for multiple severe illnesses typically present near death. In fact, much of what has been labeled the "high cost of dying" is just the cost of caring for severe illness and functional impairment, according to the authors of a recent study that was supported by the Agency for Healthcare Research and Quality (HS10561). Decedents' costs are, roughly speaking, not much different from those of survivors with similarly complex medical needs, note the researchers. They found that 38 percent of Medicare patients have some nursing home use in the year of their death, and hospice care is now used by half of dying Medicare cancer patients and 19 percent of dying Medicare patients overall.... ....For the mid-1990s, decedents' per capita Medicare program outlays were about six times higher than outlays for survivors. A typical decedent suffered from nearly four serious diseases in the last year of life, while survivors averaged slightly more than one in a typical calendar year. About three-fourths of decedents had some mention of heart disease in the claims data; roughly one-third had cancer, stroke, chronic obstructive pulmonary disease, or pneumonia/influenza; and more than one-fourth had some form of dementia. Yet, when compared with similarly old and sick survivors, decedents had less than 30 percent higher medical costs during the last year of life, perhaps attributable in part to a more likely episode of nursing home care during the year." This suggests that there has been 'covert care rationing' going on (for longer than I expected, as some of these studies are from the early 90s): http://www.agingresearch.org/brochures/7myths/7myths.html "...people age 80 and older in this study were less likely to be admitted to teaching hospitals and more likely to enter lower-cost community hospitals.9 Again it appears, as the SUPPORT researchers noted, that some informal age-based rationing of hospital care is in effect....The trend, moreover, appears to be toward less hospital care for the dying as age increases, in contrast to the popular assumption. The NCHS data on place of death shows a sharp drop in hospital deaths after age 84 and a steady increase in the nursing home as place of death after age 65..." Nursing home costs are a considerable part of costs: "...The Survey of the Last Days of Life, conducted by the National Institute on Aging, suggests that most older people spend the majority of their last 90 days of life outside of hospitals, although about half transfer to a hospital in the last week or two of life. This study of more than 4,000 deaths in Fairfield County, Connecticut, also found that the number of days that elderly persons spent in nursing homes in the last 90 days of life increased dramatically with age. "Researchers have also looked at nursing home costs. The study of 261 patients in Palo Alto, found that nursing home and home health care costs increased sharply after age 80, even as hospital costs dropped by 50 percent. Likewise, a 1988 study of 4,349 Medicare and Medicaid beneficiaries in Monroe County, New York, found that the percentage of Medicare and Medicaid expenses for nursing home care rose sharply with age from 24 percent for the "young old" (65 to 74) to 62 percent for the "oldest old" (85 and over). But Medicare/caid does not cover all of the costs: [next page of first cite above] "...Data from the 1987 National Medical Care Expenditure Survey indicates that for those aged 65 or over who died in 1987, Medicare accounted for 48 percent of health expenditures during the last six months of life (52 percent for noninstitutionalized decedents and 39 percent for those in institutions) (calculated from Table 2 in Cohen, Carlson, et al., 1995). For all beneficiaries, in 1992, Medicare covered barely half (53 percent) of health care expenses with 14 percent, 10 percent, 20 percent, and 3 percent of expenses covered by Medicaid, private insurance, beneficiary out-of-pocket spending, and other sources respectively (Gornick et al., 1996)... "...For those who qualify for federal-state Medicaid, the program is an important source of payment for nursing home care. It pays about 47 percent of all nursing home bills, compared to Medicare's 8 percent (Levit et al., 1996)." A recent RAND study surprisingly found that hospice care cost more than traditional medical care in the Medicare population: http://www.rand.org/news/press.04/02.16.html Yet, WRT healthcare rationing, this 2002 report "suggests that the financial incentives for hospitals and physicians be redirected, in the context of end-of-life care, away from aggressive, inpatient medicine and toward rewards for providing palliative care and consultative services outside of the acute-care setting." http://www.hcfo.net/030403.htm (downloadable large file; I haven't looked at it yet) Here's a pretty good posing of the 'futile care' issue, including the dangers inherent in such a label: http://www.mediscene.com/medpub/futile.htm "Futility has been invoked as a concept to guide physicians in avoiding the provision of inappropriate care. The concept is complex and value-laden. It addresses a number of distinct concerns that are often confused, making the use of the term ambiguous, if not misleading. "Invocations of futility have often been used to avoid directly facing how one ought to incorporate considerations of chance of success, cost, life expectancy, and quality of life into decisions regarding what therapeutic options should be offered to patients and their families, how triage policies should be developed, how and when do-not-resuscitate orders may be written, and how access to high-cost, low-yield treatment may be limited. "In order for futility determinations to be made appropriately, they must honestly acknowledge the considerations invoked in determining futility..." And here the outraged, whose real concerns I understand, but they offer few if any practical solutions to the healthcare cost dilemma: http://www.haciendapub.com/huntoon2.html "It is no coincidence that the debate over physician-assisted suicide and euthanasia has arisen at a time when managed care has been forced on employees and socialized medicine is being surreptitiously implemented in a piecemeal fashion in our country. There has been increasing talk of a "right to die" and of "death with dignity." Marching close behind those who insist on the "right to die" are those who feel it would be in society's best interest to create a duty to die..." I didn't investigate, but this author has numerous hits on a Google 'futile care' search and is extensively referenced in the above: http://www.zmag.org/content/print_article.cfm?itemID=2087§ionID=47 "...If Sawatzky has a heart attack, Helene wants him to have CPR. But she was told by Riverview that they won't do it, that CPR would be "futile." Over Helene's objections, a DNR order was entered upon his medical chart. She sued to require his own doctors to treat him in a medical emergency. On November 11, she won a victory. But it is only temporary, pending court proceedings..." Debbi __________________________________ Do you Yahoo!? SBC Yahoo! - Internet access at a great low price. http://promo.yahoo.com/sbc/
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