The Cost of End of Life Care

I had an interesting conversation on the way back to the office today with my colleague. We had just attended a lecture around health care reform and the goals that it hopes to obtain – lower health care costs with better health outcomes. During the lecture, my colleague didn’t have the opportunity to ask a question, but wondered why they never brought up “end of life costs in health care.”  His thoughts were that the last 6 months of life are very costly (in regards to health care dollars) because of hospitalizations, medications, ventilations, etc.  He also mentioned that physicians should be reimbursed more for having end of life discussions with family members and explaining the details around making a person a DNR (Do Not Resuscitate).

I listened and then gave my two cents regarding this topic. I do not feel that end-of-life care is the most expensive in our health care system. Yes – it can be costly for those who stay in the hospital and are ventilated for extended periods of time. But, I do not believe these are the patients that are terminal from cancer or chronic disease. These are the patients that have sudden accidents or strokes or heart attacks that may have been in fairly good health prior to this devastating event.

These are costs and events that will unfortunately always be part of health care costs. The only way to cut down on this would be to better manage chronic conditions that may lead up to the stroke or heart attack. That is what I believe is the highest cost associated with health care today – poor chronic disease management. I feel that we should address chronic disease in our patients, from initial onset to self-management tools, to follow up care. Additionally, we need to form an ongoing relationship with our patients so that all barriers to care and treatment can be discussed. We can educate these patients on when and where to receive care and how to stop over-utilizing the ER. These things can significantly reduce health care costs. Better chronic disease management is a goal of health care reform and was discussed today.

When I think of “end of life care,” I automatically think Hospice. I think DNR. I think good quality of life surrounded by loved ones in a home or hospice settings. Although this may be an extended period of time, I do not see how it can be the most expensive health care cost. The majority of patients are not on machines that monitor vital signs, most are not taking many medications and family members generally become the primary care givers. Additionally, the equipment needed for the patients can be borrowed from hospice or other facilities. I know there is cost of care, but I do not agree that end of life is the most costly.

To the point of reimbursing doctors to have end of life discussions with their patients, this does happen regardless of monetary incentives. It is a responsibility as a health care provider to inform the patient and family members of health care status, diagnosis and prognosis. When the prognosis is poor or a patient is considered “terminal,” (less than 6 months life expectancy) end of life discussions occur and usually, hospice is consulted. Additionally, the talk of DNR status and patient wants and needs addressed. In the best case scenario, the patient is still of sound mind and can make these decisions on their own. They can determine what life saving tasks they would or would not like to happen. In other cases, a POA (Power of Attorney of Heath Care) is pre-determined and has that decision making ability for the patient surrounding DNR status.

Although my opinion about what the highest costs of care are, I do look forward to the future of health care reform. I look forward to better collaboration, coordination and access in health care.  I look forward to lowering health care costs and gaining better health outcomes. I look forward to working alongside many primary care doctors as we transform health care into a more patient-centered approach.

6 Comments

  1. Howard Lutz November 8, 2013 Reply

    Here is an article from Kaiser Family Foundation http://www.kaiserhealthnews.org/Daily-Reports/2013/June/04/end-of-life-care.aspx 28% of spending is during the last 6 months of life. Hospice does not drive this spend (hospice is cost and QALY preferred) it is driven by invasive and unnecessary procedures performed on terminal patients which extend length but not quality of life. One potential path to savings is better incentive alignment. Several years ago the Right vilified the Left for “death panels”. I seldom agree with the Left but in this case the death panel was simply allocating tax dollars towards the most efficacious care. If an individual can pay out of pocket they should be allowed to do anything they want to stay alive “at all costs”. The issue is when the spend is tax dollars. Of course, chronic disease management is important as well, and I was not discounting the value of proactive management of those conditions. Best path for all of it though is ensuring all stakeholders have significant SKIN IN THE GAME!!

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