MedicalResearch.com Interview with:
William B Weeks, MD, PhD, MBA
The Dartmouth Institute
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: The background for the study is that a common narrative is that end-of-life healthcare costs are driving overall healthcare cost growth. Growth in end-of-life care has been shown, in research studies through the mid 2000’s, to be attributable to increasing intensity of care at the end-of-life (i.e., more hospitalizations and more use of ICUs).
The main findings of our study are that indeed there have been substantial increases in per-capita end-of-life care costs within the Medicare fee-for-service population between 2004-2009, but those per-capita costs dropped pretty substantially between 2009-2014. Further, the drop in per-capita costs attributable to Medicare patients who died (and were, therefore, at the end-of-life) accounts for much of the mitigation in cost growth that has been found since 2009 in the overall Medicare fee-for-service population.
MedicalResearch.com: What should readers take away from your report?
Response: Readers should understand that the trajectory of growth in per-capita end-of-life care costs changed pretty dramatically in 2009, having been rising fairly rapidly before 2009 and falling somewhat substantially since 2009. They should also be aware that end-of-life care consumes substantial Medicare resources: despite representing about 4% of Medicare fee-for-service enrollees, decedents accounted for about 40% of overall annual per-capital Medicare fee-for-service expenditures. The good news is that this same population accounted for the majority of per-capita expenditure reductions between 2009-2014.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: The key question is, “Why did this happen?” We have proposed a study to ARHQ to determine the answer to that question. Seemingly, causes could be due to changes in supply and type of providers (for instance, after passage of the Accountable Care Act, providers might have turned their attention toward new enrollees and away from Medicare patients near the end of life; alternatively, the growth in numbers of Palliative Care physicians might result in more conservative treatment being provided). But another possibility is that the findings are due to changes in the demand for healthcare services. For instance, the general population might be more desirous of conservative care at the end-of-life, and cultural norms about what should happen at the end of life might have changed in the last decade. But a final possibility is that the financial crisis of 2008 resulted in an increase in cost-considerations when patients and their families were making end-of-life decisions – cost constraints might have caused them to refuse care, even care that they wanted but could not afford.
Hopefully, our grant will get funded and we can determine whether the trends we uncovered have persisted and what is behind them.
Weeks WB, Kirkland KB, Freeh C, Weinstein JN. Proportion of Decedents’ Expenditures Among Recent Reductions in Medicare Expenditures. JAMA Intern Med. 2018;178(5):717–719. doi:10.1001/jamainternmed.2017.8213
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