Better Final Days

Better Final Days

By Shannon Brownlee, New America Foundation
Los Angeles Times | November 26, 2005

Whenever Americans stop to think about how they want to die, most conclude that they don't want to spend their last days in a hospital bed. They don't want to be stuck in an intensive care unit unnecessarily, or hooked up to machines if they can possibly avoid it. And they do not want a lot of tests and procedures, especially painful ones, if undergoing them won't improve their chances of surviving -- or at least make their passing a little easier.

But that's exactly the sort of high-tech death thousands of elderly patients with chronic illnesses are suffering, depending on which hospital they find themselves in during the last two years of life. A landmark study, published by a team of Dartmouth University researchers in the journal Health Affairs last week, looked at the care received by Medicare recipients who died in 226 California hospitals between 1999 and 2003.

The study found huge variations in the amount of care being delivered in different hospitals to similar, chronically ill patients. Let's look first at UCLA Medical Center, a hospital that is renowned for its geriatric services. The average Medicare recipient who died there spent 19 days in the hospital during the last two years of life, 11 of them in the ICU. He saw a doctor in the hospital 52 times, and Medicare paid $71,922 for his care.

At Garfield Medical Center in Monterey Park, the average patient fared worse: He spent 23 days in the hospital, saw a doctor a whopping 92 times and cost Medicare $106,254.

But if that same patient had lived instead near UC Davis, he would have been hospitalized for just over 11 days, been in the ICU for about seven days and seen one-quarter the number of doctors for a cost to Medicare of $55,323.

Did the extra care make these chronically ill patients live longer or better? Probably not, according to a previous study by the Dartmouth team. That study, published in 2003 in the Annals of Internal Medicine, concluded that Medicare patients in higher-spending regions "receive more care than those in lower-spending regions but do not have better health outcomes."

Hospitals will correctly argue that there's no way to know ahead of time which patients are likely to recover with aggressive treatment and which are in their last few months of life. And academic medical centers such as UCLA will say they provide more care because they attract sicker patients.

But are the hospitals that are spending the most any better at helping patients get well? Most patients would agree that all those days in the hospital, doctor visits and often unpleasant tests and treatments would be worth it if it actually made a difference in the quality and length of their lives. But a growing body of research suggests that it does not. And more spending does not mean that hospitals are better at delivering proven treatments, like pneumonia vaccines or beta blockers for patients admitted to the hospital with a heart attack. In fact, patients in hospitals delivering the most intensive care were often less likely to get tests and treatments that are known to work, according to the latest California study as well as previous research.

What's more, winding up in those intensive-care hospitals may actually increase a patient's chances of dying by as much as 2% to 6%. That's because hospitals, for all their power to deliver lifesaving treatments, can also be dangerous places where every drug, every treatment, every test carries the risk of error and harm.

Americans have come to believe that more healthcare equals better health. But what these studies show is that's not always true. And as anybody who has spent time in an ICU can tell you, a lot of treatment for terminal conditions can certainly make a misery of a patient's final few weeks of life.

Certainly hospitals such as Garfield and UCLA, and the doctors who work in them, generally don't think they are delivering excess care--or that they are failing to provide needed care. But doctors and hospitals are paid more for doing more, not for doing better. They often profit from giving excess care and lose money when they provide some kinds of care that really makes a difference, such as monitoring a heart failure patient once he goes home.

Those who study healthcare also note that the supply of medical resources -- not how sick the patients are -- often determines what care patients get. The more beds a hospital has, the more patients will be hospitalized, and the more MRI machines a hospital buys, the more scans will be ordered. And as much as Americans like being able to see their specialists, having more specialists involved can complicate care.

How can this problem be fixed? Patients and their distraught families cannot possibly be expected to decide what kind of care is appropriate. It's up to insurers, Medicare and Congress to restructure the financial incentives to make sure that good care pays.

Whenever payers begin talking about cutting costs, Americans begin worrying about rationing. It would be rationing if hospitals or insurers were to withhold effective care in order to save money. This isn't about denying elderly patients treatment that could help them; it's about not inflicting expensive treatments that aren't likely to improve or substantially prolong their lives.

Before Americans broach the topic of rationing, we ought first to make our hospitals deliver better care more efficiently. If every hospital in the country were to hit the benchmark of those that keep unneeded care down and quality up, it would reduce Medicare costs by 30%.

The Dartmouth group is working on a similar study of hospitals across the nation. Acting on its findings could go a long way toward averting the fiscal train wreck that is facing Medicare in the next 50 years, when costs are projected to rise to $2.67 trillion. It might also make the end of life a little easier for millions of Americans.

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