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% chance of dying in a hospital ICU. The tab for your doctor and hospital care will run just over $23,000.
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% chance of dying in an ICU. You'll likely die at home, with the support of a hospice program. Total tab: slightly more than $14,000.
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"There's a tremendous opportunity for both improving quality and enhancing efficiency in the care of people with very serious illnesses at the end of life," says geriatrician Joanne Lynn, who spent much of her career at think tank RAND studying end-of-life care.
She says substantial progress could be made in slowing rising costs if the U.S. health system could find better ways to reduce hospitalizations for people at the end of life, such as providing more in-home services.
Portland and Miami reflect that tremendous variation among regions. The most expensive city out of 309 hospital referral regions is Manhattan, at a cost of $35,838 for the last six months; the least expensive is Wichita Falls, Texas, at $10,913.
Estimates show that about 27% of Medicare's annual $327 billion budget goes to care for patients in their final year of life.
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Why is it more expensive to die in some areas of the country than others?
The number of doctors and hospital beds is part of it: The more there are, the more care a person gets. Also playing roles: the expectations of patients and the practice patterns of doctors.
Portland has fewer ICU beds and specialists per person than Miami, which is also more multicultural, with a greater variety of views on end-of-life medical care.
But experts on the end-of-life care say one main reason for the vast difference between the two cities may be that in Oregon, doctors, or staff at hospitals and hospices, encourage patients with life-threatening illnesses to talk about the end of life, what kind of medical care they want and where they want to die. The state has a history of such debate: Oregon residents have long supported palliative care, a term usually used to describe medical care for the terminally ill that focuses more on comfort treatments than cures. And, in 1994, voters there became the first in the nation to approve doctor-assisted suicide, a referendum signed into law in 1998.
"We have fewer hospitals and ICU beds than Miami does and, yes, that's a factor. But making a plan and how everyone supports you to have that plan is what makes the difference," says Susan Tolle, a medical doctor and director of the Center for Ethics in Health Care at Oregon Health & Science University.
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Complicating matters is that medicine often doesn't know what the most effective treatments are. And doctors are trained to save lives. As a result, some patients may be pushed into more than they want by a medical system that values doing something over doing nothing, even when futile.
"One of the things that frustrates us all is to see care being provided in an absolutely futile situation ... and doctors and hospitals are not accountable but are also being rewarded (financially) for that (futile care)," says John Santa, medical director for the Center for Evidence-Based Policy in Portland.
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She and others say there's not enough money to give everyone a treatment with a one-in-a-million chance of success. "None of us wants to bankrupt our community on desperate, long-shot treatments," Lynn says. "The question is, how do we build a sustainable health system?"
Those questions about what care to give and when to quit are deeply personal. A USA TODAY/Kaiser/ABC poll of 1,201 Americans taken by telephone in September found the public divided on the answers.
When asked if it is better to keep a terminally ill person alive as long as possible, regardless of the expense, or to make a judgment as to whether it's worth the expense, 48% said it's better to weigh the costs, compared with 40% who said to keep the person alive as long as possible, regardless of the cost.
Among those 65 and older, 60% said expense should be considered, compared with 28% who said cost should not enter the decision. The nationally representative poll has a margin of error of plus or minus 3 percentage points.
Improving quality of care
Still, not everyone agrees that slowing spending at the end of life is a panacea for rapidly rising health costs. Such costs are driven by a host of factors, of which the amount spent in the last six months of life is but a part. "There are so many things that would result in very substantial resources being saved, and (end-of-life care), on my list of things, is not at the top," says Santa.
Things closer to the top of his list include unnecessary back surgeries, hysterectomies and what he calls an over-reliance on some expensive brand-name drugs when generics would work just as well.
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