Costs at the End of Life

Abstract

Many elders require supportive services, with many costs covered by Medicaid. Once terminal illness sets in, palliative care and hospice may help control cost while ensuring quality. This commentary reviews trends in cost at the end of life and describes selected strategies to improve patient-centered care in North Carolina. L ife expectancy and medical innovation in the United States have increased dramatically over the last century [1]. The rise of antibiotics and critical care technologies (eg, ventilation, dialysis) allows people to live longer, with evidence indicating expansion rather than compression of morbidity between 1998 and 2008 [2]. This expansion of morbidity-as well as the increasing incidence of dementias at older ages and social trends around caregiving-challenges the ability of families to care for their aging elderly at home. The shift toward long-term care settings as elders approach the end of life is a driver of health care costs, making it an important societal conversation. While evidence indicates that hospitalizations decline with age [3], total costs remain high due to increasing incidence of chronic disease, declining functional status, and increasing use of longterm care services.The historical roots of health care reform in the United States yielded a Medicare system that does not cover longterm care costs, leaving those costs primarily to individual private pay or Medicaid. At the patient level, Medicare beneficiaries in need of long-term care must spend down certain assets to qualify for Medicaid, which will then kick in to cover long-term care costs. Long-term care can take diverse forms, including home care, nursing homes, and long-term acute care hospitals. In 2016, 21% of Medicaid costs in North Carolina (ie, $2.6 billion out of a total of Medicaid spending of $12.4 billion) were attributed to long-term care for younger, disabled individuals as well as the elderly, with community-based care accounting for 56% of long-term care costs [4].Compared to nursing home care, evidence suggests home-and community-based programs offer better quality of life, especially for patients with certain conditions, including dementia [5]. Various strategies target both costs and quality, including Home and Community-Based Service (HCBS) Waivers at the state level that act to support home-based care to keep people in their communities longer [6]. Innovations such as Continuing Care Retirement Communities (CCRCs) support independence and agingin-place, but they are primarily an option for persons with higher incomes who can buy into the model early. Longterm acute care facilities that support the chronically ventilated, critically ill-a smaller proportion of long-term care patients-present a different set of barriers to both cost and quality of life for residents, including protracted stays dependent on technology (eg, chronic ventilator support) that cannot be readily transferred to a community setting or even a less-equipped nursing home [7].Regardless of the location of long-term care, another ...

Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews

“…Most approaches focused on the hospital setting. Hospital costs are known to escalate in the last phase of life, with questionable benefit to patients [90,91]. Furthermore, the evidence is subject to a range of methodological limitations as discussed above.…”