The Cost of End-of-Life Care

Failure to standardize end-of-life care can add cost to the health care system

For chronically ill patients who are hospitalized for months or years, knowing that they are leaving loved ones deep in medical bills is yet another burden to carry.

But according to a report released last week by researchers at Dartmouth Medical School, such intensive care of end-of-life patients may not be necessary, and may in fact add billions of dollars to the health care system but does not necessarily improve the quality of care.

The study focused on patients suffering from chronic ailments and tracked the last two years of their lives to compare practices and spending across hospitals nationwide.

Elliot S. Fisher ’74, one of the co-authors of the study, said that the results highlight the dramatic differences in how hospitals care for end-of-life patients. Given that a great deal of medical literature shows a lack of correlation between more aggressive medical care and the prolonging of life, Fisher said, the findings indicate that the failure to standardize end-of-life care can be immensely costly to the health care system.

“There is a real opportunity for substantial savings in the care of patients with serious illness,” Fisher said. “We spend twice as much with no gain in survival.”

The report found that Harvard-affiliated Mass. General Hospital (MGH) would have saved over $54 million in Medicare reimbursements from 2001 to 2005 if it had treated patients with the same level of care as the renowned Mayo Clinic in Rochester, Minn. One of Harvard’s other affiliates, Brigham and Women’s, would have saved $38.5 million.

Meanwhile, patients at MGH spent an average of 17 days in the hospital with almost 40 doctor visits, while those at the Mayo Clinic were hospitalized five fewer days and had 16 fewer encounters with physicians.

“We definitely have a more aggressive attitude at the end of life than in the rest of the country,” said Thomas H. Lee, Jr. ’75, the network president at Partners HealthCare, the group that owns both MGH and Brigham and Women’s. “There is a culture where people hear of medical advances all the time and may be less inclined to give up,” he said.

Lee, who was once a Crimson editorial editor, noted that the report’s data was not adjusted for differences in medical costs by state. The wages of medical professionals in Massachusetts are about 20 percent higher than those in Minnesota, Lee said.

J. Andrew Billings, the director of palliative care service at MGH, said that he found the Dartmouth study “slightly inflammatory,” adding that it is difficult to make any conclusions about the quality of care based on the data.

“Just because there is no evidence that there is no difference [in the quality of health care] doesn’t mean that there are no differences,” Billings said. “It’s just wrong. The quality of care can vary enormously for people—it’s just that they still die.”

‘A WORLD OF ISLANDS’

In addition to highlighting the cost savings that may be found by reforms to end-of-life care, the study also raised the issue of whether or not the desires of patients are actually honored.

Fisher said that while most end-of-life care is currently determined by the health care systems, patients should be able to align their own care with their individual preferences.

According to a report by the Mass. Health Care Quality and Cost Council, patients and their families are usually not familiar with their end-of-life care options. As a result, patients do not always discontinue invasive treatments even when they may want to do so.

According to the report, over 70 percent of Americans say that they would prefer to die at home, but just one fifth of deaths in Massachusetts occurred in homes in 1997. While there has been some legislative action to increase end-of-life options, the effect has been minimal. By 2005, the number had only risen to 22 percent.

The commonwealth is continuing its efforts, however. Massachusetts recently set specific goals and expectations to ensure that patients’ wishes are respected, according to James B. Conway, who sits on the Council as representative from the Institute for Healthcare Improvement, a non-profit organization based in Cambridge.

“This is not something that will be solely fixed on one hospital, one clinic, one doctor’s office at a time,” Conway said. “It’s going to require coordination from everybody, from the people at health care companies to the ambulance driver. The community will be coming together in the name of the patient.”

Conway added that Massachusetts will kick off the initiative with a campaign to inform the public of end-of-life care options, and will put in place a pilot program to find a method to capture patients’ wishes, which has been very successful in states like Oregon.

“Our next big step is a cultural one,” said Lee, who is also a member of the Council. “Adopting a more thoughtful approach to end of life care is really something that has to be discussed in churches, schools, and senior centers.”

Lee said that for physicians and patient families alike, it is difficult to “show restraint” in choosing care options even when the chances of saving a patient’s life are low.

“We live in a world of islands. Doctors do their piece, nurses do their piece, hospitals do their piece,” Conway said. “We haven’t yet put together a system to support the delivery of end of life care.”

—Staff writer June Q. Wu can be reached at junewu@fas.harvard.edu.

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