Bill Keller has an insightful piece on end of life care in England v. the USA, using the example of the recent death of his father in law. First, let me say that it is brave for a family to share such a personal story, and I want express condolences to the family.
A few policy thoughts on Keller’s piece:
- I agree with his notion that focusing on end of life care with the expressed purpose of saving money is likely to prove not only politically difficult, but it is hard for such efforts to work. That is because the “last year of life” is an inherently retrospective concept, and you don’t know when the last year started, until it ends. This makes it very hard to know when to shift into “cost saving” mode.
- One interesting note is that the proportion of total spending using the “last year of life” metric in the NHS is quite similar to that in the U.S. The tremendous difference is in the level of spending (on the order of $2 for $1 per capita) between the two nations.
- The citation Keller uses from Zeke Emanuel on limited cost savings of hospice is from 1994 and there is more recent work that does demonstrate that hospice reduces Medicare expenditures as compared to similar non-hospice users that has been published in the past several years (sorting out selection bias is a tremendous methodological challenge in this literature, meaning those choosing hospice differ from those who don’t in ways the impact health spending). One of the papers that sorted this out is my paper with colleagues from Duke. There are others.* I reviewed a new paper two weeks ago for a top journal that actually confirms and extends the findings from my paper (while including a richer set of matching variables). So, hospice remains just about the only thing of which I know that holds out the hope of reducing costs while improving quality of life (typically we are left to assess whether something with a marginal benefit at greatly increased cost “is worth it.”
- A reality is that the hospice benefit was “sold” in 1982 as a means of cost savings when it was added to the Medicare program. A recent paper of mine on some of this history.
- Medicare hospice policy greatly needs to be updated. The insanity of “death panels” and our inability to talk reasonably about something that will happen to each of us (death) greatly hinders good policy. My book frames this inability to face limits as a key source of inability to reasonably address health care costs.
- The antidote to what I have termed insanity, is to seek to ask three basic questions about all care, regardless of our belief about someone’s prognosis: does it improve quality of life? does it extend life? how much does it cost? These questions need to become part of our broad cultural dialogue about health care, as well as explicit parts of evidence based policy making.
For example, see:*Pyenson B, Connor S, Fitch K, Kinzbrunner B. Medicare cost in a matched hospice and non-hospice cohorts. Journal of Pain and Symptom Management 2004;28(3):200-12.
Shugarman L, Campbell D, Bird C, Gabel J, Louis T, Lynn J. Differences in Medicare expenditures during the last 3 years of life. Journal of General Internal Medicine 2004;19:127-35.
[Cross-posted at The Reality-based Community]