Dartmouth Publishes Costs to Care for Chronically Ill at End of Life, Compares Institutions
The newest edition of the Dartmouth Atlas of Care was released. This year’s report is titled Tracking the Care of Patients with Severe Chronic Illness. The executive summary, as well as the full publication, are available online. One of the key messages in this year’s report is the variation in care patterns for Medicare recipients with severe disease across the country; this report focused on treatment during the last two years of life.
The report notes that over 90 million people in the U.S. have at least one chronic condition. Treatment during the last few years of life has been a recent area of investigation; evaluating whether more care is equivalent with better care during this time frame.
The amassing data indicates that providing more care, which is clearly more costly, is not equated with better care. Nevertheless, there is limited quantifiable data to support this point and, thus no evidence-based guidelines to support this practice. As such, some clinicians and institutions may continue to provide the most aggressive and intense care to support patients during the end of life. This cost is under scrutiny in light of the intensified efforts to decrease overall healthcare costs.
An editorial published in the New York Times noted the significant disparities between healthcare institutions in terms of the costs to manage patients with chronic conditions, as detailed in the Dartmouth publication. Specifically, costs paid by Medicare to treat patients during the last two years of life were compared. Five well-renowned teaching hospitals were compared; Johns Hopkins, the Cleveland Clinic, UCLA, the Mayo Clinic, and Mass General.
Costs were highest at UCLA ($93,000 per patient), followed by Johns Hopkins ($85,000). Mass General was next at $78,000. The Cleveland Clinic and Mayo Clinic were substantially lower, at $55,000 and $53,000, respectively. The differences cannot be attributed to prevalence of disease. Variation in disease prevalence explains less than four percent of variation in costs paid out by Medicare. The factor most associated with cost was the volume of care delivered, rather than the prices paid for services.
A similar comparison was also completed in 2006. The report authors examined data for the factors that may explain increased care utilization. One conclusion is that the Medicare fee-for-service system rewards care utilization, which translates to higher earnings as care is delivered.
Another suggestion is that improvements in systems to support care coordination are paramount. Within that, there must be attention to utilization of home-based care and services, which is less expensive than any other care model, including nursing homes.