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The
Cost, Choices of Health Care in Final Months
By Betty Falcao, Guest Columnist, The Ithaca Journal
September 19, 2008
Health care in the last months of a person's life is expensive. What kind of care do people want? What are the costs? Is more always better?
What do we want? A Tompkins County survey in 2000 found that most people (74 percent of the 688 respondents) wanted to die at home; a strong second choice was a hospice residence. What actually happens? In 2007 in Tompkins County 36 percent of people died in the hospital, 25 percent in nursing homes, 29 percent at home, 7 percent at the hospice residence and 2 percent in other places.
Patients and their families, wherever their place of death, want alleviation of symptoms such as pain and shortness of breath, the opportunity to talk with doctors and others about death and dying, and the knowledge that they will be cared for and comforted as they approach death.
The many components of care and the variation in the health status of individuals make each situation unique. However, average expenses can give us some idea of the financial impact of end-of-life care.
There are five primary ways people cover the cost: Medicare (ages 65 and over and those with disabilities), Medicaid (for low-income people), insurance, out-of-pocket and unpaid care by family and friends.
People spend an average of 16 years on Medicare, yet about 27 percent of Medicare's annual budget goes to care for patients in the final year of their life. These high costs reflect care for multiple severe illnesses typically present near death.
Using 2005 data (the latest available year), Tompkins County had 11,161 Medicare participants. If they followed the national pattern of care, this 27 percent would have been about $38 million spent for the fewer than 600 people who died that year.
Comparable Medicaid data is not readily available. However, they cover about 75 percent of nursing home care; Medicare pays only about 5 percent.
Even with health insurance, people typically have high out-of-pocket expenses such as for deductibles, co-pays and home health care. Many use their “rainy day” savings during this time.
Without the unpaid care of family and friends, the above costs would be significantly higher. Some informal caregivers even leave their jobs to provide care to terminally ill family members.
Signing up with hospice can help with the family finances. The Medicare hospice benefit covers the cost of physicians, nurses, physical therapists, home health aides and others. It also pays for medications related to the primary illness, and the durable equipment provided to keep a person comfortable.
Is more care always better? The 2006 Dartmouth Atlas of Health analyses the geographic variation in the use of medical care:
* If you are dying in Miami, the last six months of your life might well look like this: You'll see doctors, mostly specialists, 46 times; spend more than six days in an intensive care unit and stand a 27 percent chance of dying in a hospital ICU.
* But spend those last six months in Portland, Ore., and you'll go to the doctor 18 times, half of those visits with your primary care doctor, spend one day in intensive care and stand a 13 percent chance of dying in an ICU. You'll likely die at home, with the support of a hospice program.
Editor's note: Hospicare and Palliative Care Services is marking its 25th anniversary by celebrating its history, recognizing the people cared for — more than 3,000 individuals and families — and addressing challenges found in end-of-life care such as ethical and spiritual issues, and an aging population.
This is the fifth in a series of monthly columns.
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