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Dartmouth, D-H Study Tracks Drop in End-of-Life Care Costs



Valley News Staff Writer
Thursday, May 17, 2018

Lebanon — A study published this month by Dartmouth College and Dartmouth-Hitchcock researchers found that spending for medical care at the end of life appears to be declining.

The study, which used Medicare data from the Dartmouth Atlas Project for people between the ages of 65 and 99, found that while end-of-life care costs increased between 2004 and 2009, they decreased from 2010 to 2014.

“We were surprised to find this kind of downward trend in per capita spending,” said Dr. William Weeks, a professor at The Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth’s Geisel School of Medicine.

Weeks, the lead author, said his surprise arose from the fact that previous studies have shown end-of-life care costs to be increasing.

The findings, published this month in the Journal of the American Medical Association Internal Medicine, are significant because such a large portion of overall Medicare spending is involved with end-of-life care, Weeks said.

“Even though it’s declining, people at the end of life are still consuming a lot of resources,” Weeks said.

Weeks and his co-authors — who included Dr. Kathryn Kirkland, Dartmouth-Hitchcock’s chairwoman of palliative medicine, and Dr. James Weinstein, D-H’s immediate past CEO — looked at mean annual expenditures for Medicare part A and B participants, a population that ranged from about 27 million to 25 million in the years studied, 2004 to 2014. The study looked at mean annual data for all enrollees and the prior two years of care costs for those who had a chronic condition and died.

They found that expenditures in six categories — durable medical equipment, outpatient, hospice, physician, home health and inpatient care — all increased in the last two years of life for those who died between 2004 and 2009 and then decreased for those who died from 2010 to 2014.

Overall, per capita Medicare expenditures increased from about $9,100 in 2004 to $10,500 in 2009, and decreased to $9,600 in 2014.

These changes were driven by care costs for those who died. Between 2010 and 2014, despite accounting for just over 4 percent of enrollees, those who died accounted for nearly 55 percent of the Medicare savings that could be attributed to practice changes, the study found.

“But for that, care costs would have accelerated,” Weeks said.

But Melissa Aldridge, an associate professor in the department of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York City, disputes the popular idea that the highest health care spending happens in the last year of life.

A paper she published in the American Journal of Public Health in 2015 found that just 11 percent of the people with the highest health care costs in 2011 were in their last year of life.

“I think the important thing to think about is what we know is that health care costs are not driven by end of life spending,” she said in an interview Thursday.

Aldridge said that looking at per capita mean annual data, as the Dartmouth researchers did, does not provide a clear picture of what is driving overall health care costs. It doesn’t look at which individuals, with which types of conditions, cost the most to treat.

“They’re really the ones that we need to focus on,” she said.

In addition, she said, the Medicare data does not include other costs associated with health care, such as Medicaid, out-of-pocket costs for nursing homes, managed care costs or assisted living costs.

“It’s not really ... reflective of what’s going on,” she said of the Medicare data.

Weeks’ study did not attempt to answer the question of why Medicare costs might be decreasing.

“I think that the $10 million question is what change has finally led to this happening,” said Joan Teno, a professor and researcher at Oregon Health & Science University in Portland. “That’s going to be the hard one to detangle.”

This is a question Weeks said he hopes to answer in the future.

There could be a number of reasons for the decrease in costs, he said. Perhaps it is related to the Affordable Care Act, which was enacted in 2010. Or, it could be due to patients opting for fewer medical interventions at the end of their lives, in part due to an increase in the use of advance directives. Lastly, Weeks said, perhaps due to the financial crisis patients began to think more about the cost of their care.

If an expense you’re anticipating to increase drops, Weeks said, we “might want to figure out why, so we can see if it’s going to keep going on.”

Teno said she’s hopeful that the decreasing costs Weeks found may be evidence that the shift from fee-for-service models of care to value-based models, which tie revenue to the overall health of the population cared for, are working both to decrease costs and to better match the services provided with the care that people want and need.

“This potentially could be some early payoff of seeing that change,” she said. “Let’s hope the trend continues.”

Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.