Editorial: End-of-Life Care and Cost; Dartmouth Atlas’ Puzzling Findings

Tuesday, June 18, 2013
There was good news and puzzling news last week on the dying front.

As staff writer Chris Fleisher reported Thursday, a new report analyzing Medicare data shows that patients are increasingly choosing hospice care over hospitalization at the end of their lives. The study, done by the Dartmouth Atlas Project, reported an 11 percent decrease in hospital deaths from 2007 to 2010, with the number of days patients spent in the hospital in the last six months of life falling 9.5 percent, to just less than 10 days on average. The portion of patients choosing hospice rose from 42 percent to 48 percent over that three-year period.

The results were not consistent across all hospitals or regions of the nation, of course. But at Dartmouth-Hitchcock Medical Center, the number of days patients were hospitalized during their final months fell from 10.7 in 2007 to 9.5 in 2010 — more than a full day on average. At Fletcher Allen Health Care in Burlington, the number of hospital days per patient dropped more steeply, from 11 to 8.6.

By our way of thinking, this constitutes progress, in the sense that a good death is one consistent with the values of the life it brings to an end. It seems to us that most — though by no means all — patients would prefer to spend their last days surrounded by family and friends in an environment that is more like home and less like an institution, one where the emphasis is on easing pain rather than on heroic medical interventions that can only briefly postpone the inevitable. So strictly from the viewpoint of what’s most humane, hospice care has much to recommend it, and it’s heartening that more patients and their families are taking advantage of it.

But, of course, while the quality of a patient’s final days is paramount, it is not the only consideration for a bloated health care system like America’s. The theory has long been that since so much spending occurs in the context of aggressive medical treatment at the end of life, reducing the hospital stays of dying patients would lead to lower costs.

That makes sense, but what’s puzzling about the Dartmouth Atlas report is that despite more use of hospice and less dependence on hospitalization at the end of life, “Medicare spending per patient during the last two years of life rose from $60,694 to $69,947, a 15.2 percent increase during a period when the consumer price index rose only 5.3 percent.”

The explanation offered by David Goodman, one of the study’s principal investigators, is that the fee-for-service model is to blame, because doctors are paid according to the volume of care they provide, encouraging them to provide more services. The assumption is that once the health care system shifts toward rewarding providers for keeping people healthy rather than treating them when they are sick, the cost issue will be contained.

Maybe so, but this bears further scrutiny. The rise in spending is startling in the context of less hospital use at the end of life. As we have previously noted, the much-anticipated move to electronic medical records has yet to produce the expected cost savings.

At least if the cost savings don’t materialize in this case, many individual patients will end their lives in more comfortable and humane circumstances. And that’s undeniably good news.

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