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11/15/2016

Making Progress in Improving End-of-Life Care

This past week the JAMA Network and
the Kaiser Family Foundation published a one-page graphic providing the latest
data and information about Medicare patients and end-of-life care. JAMA.
2016;316(17):1754. In 2014, there were 2.6 million total deaths in the US; 2.1
million or about 80% of the total were persons covered by Medicare. These 2.1
million 2014 Medicare decedents accounted for 13.5% of all Medicare spending.
That is about $35,529 per Medicare beneficiary who died in 2014. Other Medicare
beneficiaries – those who did not die in 2014 – cost the system about $9,121
per person. This is a remarkable difference from 1978, when Medicare decedents
in the last year of life accounted for 28% of program expenditures. Lubitz JD,
Riley GF. Trends in Medicare payments in the last year of life. N Engl J Med.
1993;328(15):1092-1096. Interestingly, the percentage between 1978 and 1988 did
not change.

The
new data show that trends have changed over the intervening decades. One of the
more definitive descriptions of Medicare expenditures for beneficiaries in the
last year of life was published in the New England Journal of Medicine in 1993.
Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life. N
Engl J Med. 1993;328(15):1092-1096. In some respects the data may not be
exactly the same, for example, one compares payments in calendar years, and the
other the last 12 months of patients’ lives; but the trends are fairly clear
anyway:

·        
In 1988, Medicare charges for decedents were 6.9
times those for other Medicare patients. In 2014, Medicare charges for
decedents were 3.7 times those for other Medicare patients. That was a 46%
reduction in charges for end of life care from 1988.

·        
In looking specifically at the 65-year-old range
age group of Medicare beneficiaries who died in 1988 and 2014 respectfully,
decedent charges were 10.6 and 7.4 times higher than other Medicare
beneficiaries in the category. This was a 30% reduction in charges for
end-of-life care from 1988.

·        
In 2000, about 21% of Medicare patients who died
that year received hospice care; in 2014, about 46% of Medicare patients who
died that year received hospice care. The number of dying Medicare patients
referred to hospice over the 14-year period more than doubled.

·        
In 2000, total Medicare hospice spending was
$2.3 billion; in 2014, total Medicare hospice spending was $10.4 billion. This
was a 352% increase over the 14-year period. This growth comes primarily from
the time a Medicare decedent is enrolled in a hospice program. The median length-of-stay
in hospice has increased from 15 days in 1994 to 18 days in 2014, but the level
of hospice services provided was enhanced. Taylor DH Jr, et al. What length of
hospice use maximizes reduction in medical expenditures near death in the US
Medicare program? Social Science & Medicine. 2007;65(7):1466-1478.
Curiously, the percentage of adult patients who died within 7 days of entering
hospice care services increased from 22.8% in 1992 to 35.5% in 2014. Han B, et
al. National trends in adult hospice use: 1991-1992 to 1999-2000. Health
Affairs. 2006;25(3):792-799. National Hospice and Palliative Care Organization
2015 Facts and Figures. http://www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Figures.pdf.

Regardless,
Medicare expenditures for beneficiaries in the last year of life are about half
of what they were about 30 years ago. The emphasis on hospice and palliative
care services for patients who are near death appears to be making a
significant difference in a more appropriate allocation of health care resources
while improving the quality of care. But unfortunately, we still have a long
way to go in some areas: (1) Many persons 65 and older (73% of respondents)
have not discussed end-of-life care preferences with a physician and 40% have
not documented end-of-life wishes. (2) Moreover, two-thirds (68%) of physician
respondents report not having been trained to discuss end-of-life care with
patients.

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