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 one and a half 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), California ($57,914 per person), and New York ($55,718 per person)—spent at a level more than 20% above the national average of $46,412 per person.. As an extreme case, Hahnemann University Hospital-Philadelphia, PA, 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 that the patient wants the treatments being offered. But it is becoming increasingly likely that patients do not want, for example, invasive treatments (e.g. as with advance directives, and do not resuscitate directives). It is also becoming more likely, because of the increasing rate of dementia, that dying patients might not be cognitively competent to assert their wishes. This exposes that our health care system is set up to save us from dying. We need to better communicate our wishes of how we want to die. In the Patient’s Bill of Rights one of the precepts is the right to die in peace and dignity. We need to make the choice to opt out and to communicate this. It is only then can we truly express the fundamental right of patient autonomy our choice in how we die.
Mario Garrett PhD is a professor of gerontology at San Diego State University can be reached mariusgarrett@yahoo.com
© Mario Garrett 2010
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