Map of life expectancy at birth from Global Education Project.

Tuesday, August 21, 2018

End-of-life care and spending

I think I last addressed this issue quite a few years back. Ashish Jha in JAMA provides an opportunity to return to it.

'Tis oft observed that about 1/4 of all medicare spending is on people in the last year of life. Many people argue that much of this spending must be wasteful. The alternative fact, which is the true one, is that it's much more difficult to reduce spending in the last year of life than you might think.

The main difficulty is that contrary to the magical powers often ascribed to physicians, predicting life expectancy is very difficult. The obvious reason why so much is spent on the last year of life is that most health care spending is on people who are sick, and people who are very sick, and therefore in many cases very expensive, are likely to die within a year. But some of them don't -- because we spent all that money on them.

In fact, Jha demonstrates a seeming paradox. In a place where out of 200 sick people, 100 die in a year, and average spending per person is $10,000. Well, if you look at the 100 who died, their average spending was $10,000. But you have ignored the 100 who lived. Now go to another place where average spending on a similarly sick 200 people is $5,000, and 150 of them die. Now we will say that average end-of-life spending is only $5,000, and isn't that better? Not if you care about the extra 50 dead people.

So the right way to think about this is matching the care to what people want, and is best for them. Certainly people who have poor quality of life may not want to be hospitalized, and by not hospitalizing them we might save some money. They would also be more likely to die, but that's their choice. It used to be that people with end-stage dementia who couldn't eat would get feeding tubes; that's happening much less nowadays. So we might end up saving a little money by doing more of what's right for people, but don't count on it being very much.

It's still going to be expensive to treat cancer and do heart transplants, and some people will die within a year anyway. But some of them won't. Most of the reason health care in the U.S. is so expensive is actually because the price is high. Drugs are more expensive, and providers make more money. There's waste to be squeezed out for sure, but the waste isn't mostly with people who are very sick. They really do need expensive medical care.


Anonymous said...

This is one of the best posts you've made this year. Great perspective.

The real issue is the cost of the care itself, not the insurance. The healthcare industry is very self-serving. They are allowed business practices that would land anyone else in jail. Doctors invest together in a rehab facility or a private hospital and then collude to steer all of their patients there and there's little to no disclosure required.

Another HUGE issue that drives costs is the legal system. Physicians will practice "defensive medicine", ordering more tests than they would normally because they don't want to face a multi-million dollar lawsuit for missing something. Add to that the staggering insurance premiums physicians and hospitals must build into their prices...OB/GYN practice can pay as much as half a million a year in premiums.

Addressing the business practices and tort law could put a real dent into the cost of healthcare cost and it's derivative, health insurance cost.

Anonymous said...

Off topic:

Is it possible to ask for fair and equal treatment of all races without being a white supremacist?

Is any group that deals with white issues automatically a white supremacist group?

Don Quixote said...

You are a dufus, "Anonymous." There are no human "races." Homo sapiens has been around for about 200,000 years. You can fuck a person of any color and it'll all still work. The term "race" is incorrect and we need to start using the term "person." You are 99.99% genetically IDENTICAL to Aretha Franklin. Deal with it. In countries that are liberal, like Canada, people intermarry freely with others who don't look like them. I think you should marry or become best friends with a person of an ethnic minority. You'd learn a lot.

Anonymous said...

In all of your past comments, race is all you seem to want to rant about, Ms Quixote.

And now...there'e no such thing!

"Roses are red, and violets are blue
I'm schizophrenic, and so am I"

Seriously, this was a political question for Cervantes...How 'bout it Mr. C?

Cervantes said...

White people are privileged. So yes, I can and do talk about that. Race is a social construction -- it's a social fact, not a biological fact. But as a social fact, it is certainly important.

Self-dealing by physicians certainly does happen, but it's not a major contributor to medical costs. The more straightforward incentive of fee for service probably is, however.

Anonymous said...

I'm really interested in knowing the unwritten social rules on white supremacy. Not believing that any group is supreme to others simply based upon skin color, I don't understand them.

Can you be proud to be white without being a supremacist? Is that possible?

Are you automatically labeled a supremacist if you push back to any of the liberal minority agenda? Is every minority political plank to be accepted without question?

Are there secret meetings every Thursday evening around kitchen tables making up these social rules?

Somebody should write this stuff down!!

Don Quixote said...

As usual, "Anonymous"--the cowardly "Anonymous," probably the former GBB--you blithely lie. No, race is not all I talk about in my posts.

Your little nursery rhyme parody is old and it sounds as stupid coming from you as I would expect it to. Your taunts are meaningless, as are your posts.

You are, in Cervantes's words, an (irremediable) numbskull. You have no functional sense of humor or irony. You are an incomplete, deeply flawed human. Who knows why you haunt this site? You really don't belong here. But here you are. So strange.

Don Quixote said...

It is just astounding how completely daft "Anonymous" is. I really believe he's completely unreachable and unteachable. It's really bizarre and strange and sad that he goes on and on and on ad nauseum ... and almost never hears anything said (written) to him.

I believe that, on some level, "Anonymous" knows he's clueless. So he keeps coming back. But it won' take a village with this guy ... it'll take an army.

Mark P said...

"Is it possible to ask for fair and equal treatment of all races without being a white supremacist?"

Anonymous (if that is, indeed, your real name), your question is to the point. Many groups of people have been asking that white people be treated fairly and equally for many years, groups like the NAACP. I am happy that you agree that whites should no longer be have a status that is superior to all other groups. Bravo,anonymous, bravo!

Don Quixote said...

LOL, Mark. Thank you!

In a good mood tonight ... just came back from a beautiful film about the complexities of relationships and of love, called "The Cakemaker," probably a joint German-Israeli production. Of course, I love any film that has extended scenes showing the baking and cooking of great food, the one part of life that everyone shares regularly regardless of other aspects of their lives.

Anonymous said...

Ita appears that white people don't deserve a voice. If anyone speaks up, they're a "supremacist".

It's clearly a tool to shut down those who disagree with you.