The Myth Regarding the High Cost of End-of-Life Care

Abstract

Health care reform debate in the United States is largely focused on the highly concentrated health care costs among a small proportion of the population and policy proposals to identify and target this "high-cost" group. To better understand this population, we conducted an analysis for the Institute of Medicine Committee on Approaching Death using existing national data sets, peer-reviewed literature, and published reports. We estimated that in 2011, among those with the highest costs, only 11% were in their last year of life, and approximately 13% of the $1.6 trillion spent on personal health care costs in the United States was devoted to care of individuals in their last year of life. Public health interventions to reduce health care costs should target those with long-term chronic conditions and functional limitations.

Identifying the Population with Serious Illness: The “Denominator” Challenge

“…The top 5% of spenders account for nearly 60% of healthcare costs. [1][2][3][4] This spending is neither easily predictable nor consistent over time. Only 11% of the highest-cost individuals are in the last year of life, while even fewer have predictable prognoses.…”

“…Only 11% of the highest-cost individuals are in the last year of life, while even fewer have predictable prognoses. 3 Despite highly concentrated spending, care of this patient population is frequently of low quality: poorly coordinated with multiple transitions across sites of care; marked by inadequate symptom control and low patient and family perceptions of the quality of care; and potentially discordant with personal goals and preferences. [5][6][7][8][9][10][11][12] Healthcare reform aims to improve the value (i.e., raise quality while holding stable or lowering costs) of care for these highest-cost seriously ill patients.…”

“…22,23 Yet diagnoses alone fail to adequately predict costs, hospital use, mortality, or, most importantly, unmet care needs. 1,3,24,25 The addition of functional status measures and prior healthcare utilization to identification algorithms may add predictive strength, but clearly defined criteria and consistent data are lacking. 1,25 This article aims to build upon prior work by conceptually defining serious illness and describing the steps needed to operationalize this definition within a healthcare population.…”

From Disability Rights to the Rights of the Dying (and Back Again)

“…to address the central needs of nearly all Americans nearing the end-of-life" (Institute of Medicine 2014, p. 266). Given the cost of such reorientation, it is unlikely to happen in a legislative context that remains focused on reducing the cost of government expenditures in general and, more particularly, at the end-of-life (often exaggerating the cost of end-of-life care in the process) (Aldridge and Kelley 2015). Ameliorating this problem requires finding a new way to approach the care of the dying that is not predicated on a tradeoff between clinical care and cost-savings.…”

The Financial Dialogue in the Development of Medical Treatment Plans

“…Still, medical school administrators are constantly seeking avenues to improve curricula. Health care expenditure comprised 17.9% of GDP in 2011 in the United States, 11,12 and this percentage is only projected to rise. 12,13 For this reason, educating the key decision makers in health care, including physicians, about the practical financial components of providing services becomes increasingly relevant.…”