Between 1985 and 1999, the 5 percent of Medicare fee-for-service beneficiaries over the age of 65 who died accounted for one-quarter of inpatient expenditures each year. Hospital stays for all patients shortened significantly while real per-capita spending, ICU admissions, and intensive inpatient procedure use grew. As expected, decedents were more likely than survivors to receive intensive inpatient services in absolute terms. Contrary to our hypothesis, however, most measures of per-capita utilization of intensive services—including per-capita expenditures, hospital and ICU admission rates, and the likelihood of undergoing an intensive procedure—did not grow faster among decedents than among survivors over the 15-year study period. The measures of treatment intensity that did grow faster among decedents were the mean number of intensive procedures received and hospital expenditures attributable to those procedures.
Thus, greater growth of inpatient spending and intensity among decedents does not explain the stability of total Medicare spending for patients in the last year of life in the face of fewer hospital deaths. What are alternative explanations? Consider that per-capita annual treatment intensity and expenditures grew at the same rate among decedents and survivors despite policies that led to the increased use of alternatives such as hospice and a decrease in the proportion of Medicare beneficiaries who died in the hospital. If the same proportion of patients died in the hospital now as in the past, those patients would have been exposed to more opportunities for hospitalization, and total inpatient expenditures and utilization might have been higher than they are now.
The trend in ICU use deserves further exploration because it differed from most other utilization trends. The rate of one ICU admission or more grew faster among survivors than decedents. This suggests that although intensity is increasing over time, there is a systematic difference in the use of this resource between survivors and decedents. Perhaps ICU admission itself confers a meaningful survival benefit, so that patients who received ICU admission were also more likely to be in the survivor cohort. An alternative explanation is that doctors tend to admit patients to the ICU who have reasonable chances of survival, for example, patients with metastatic cancer are relatively underrepresented in U.S. ICUs (Angus et al. 2003
). Also, it may reflect postoperative ICU admissions for some of the intensive procedures whose use grew faster among survivors than decedents (e.g., bypass surgery).
Our findings are subject to several limitations. We focused only on inpatient services and did not study trends in outpatient or post-acute treatment intensity because the hospital remains the delivery site of the most expensive and technologically intensive medical care. It is possible that trends in nonacute-care hospital expenditures and treatment intensity differ from those we observed. By narrowing our study to 88 of 228 procedure categories, we selected those procedures that were most important financially to the Medicare program. Our categories were also chosen to minimize the likelihood that any could have been received in an outpatient setting by healthier patients. Our measures of utilization generally underestimated the intensity of treatment by calculating the rate of one or more hospitalization, ICU admission, and intensive procedure in the year. To address the fact that decedents are more likely to have multiple admissions and multiple procedures, we also reported mean number of claims and procedures per capita. We chose to use Medicare reimbursement, including outlier payments, as our measure of resource use since this reflects the U.S. Treasury's actual liability. These payments, though, may not represent actual costs of care provided, particularly for decedents. Even though the average DRG weight was greater for hospitalizations of decedents than survivors due to a greater prevalence of DRG-modifying complications and comorbidities, for any particular DRG, one might expect a decedent's resource use to be higher than the average cost reflected in the DRG payment more frequently than a survivor's resource use. Decedents were more likely to generate outlier payments. Outlier payments partially compensate hospitals for unusually costly cases (e.g., reimbursing 80 percent of cost-adjusted charges above the hospital's fixed-loss threshold). So inclusion of outlier payments into our calculations improves the capture of significantly above-average case resource use.
Finally, these observations are based solely upon enrollees in fee-for-service Medicare. If beneficiaries at low risk for using health services selectively enroll in managed care, our results might underestimate the growth in the decedent-to-survivor ratios, since those surviving beneficiaries left behind would be more likely to utilize intensive services than those moving into managed care. The pattern of procedure use may be different for Medicare beneficiaries enrolled in “risk plans,” under which capitation is expected to diminish the use of both hospital care and intensive procedures.
The clinical and policy implications of our findings rest on the secular trends we observed in population-based inpatient treatment intensity and spending. If increased treatment intensity does not correspond to improvements in health outcomes or patient satisfaction, then the trends we observed over the 15-year study period raise concerns regarding the efficiency of Medicare spending. Fisher found no cross-sectional associations between high treatment intensity and these outcomes (Fisher et al. 2003a
), however, this does not exclude the possibility of improvements in life expectancy over time resulting from secular trends in treatment intensity. We do not directly address the appropriateness of end-of-life treatment intensity, and acknowledge that it cannot be judged solely by survival rates among individuals who receive intensive treatments, since a survival benefit is consistent with a very high mortality rate, as long as it is lower than mortality without the treatment. Furthermore, although individual decedents were more likely than survivors to utilize intensive services, survivors outnumber decedents and, as a group, receive the majority of such services. The exceptions were procedures that are somewhat emblematic of end-of-life care: 50 percent of feeding tube placements, 60 percent of intubations and tracheostomies, and 75 percent of cardiopulmonary resuscitation attempts are done in those who will soon die.
Despite increased attention to palliative care and the increased availability and uptake of hospice services over the past 15 years, treatment intensity among patients in their last year of life has kept pace with survivors in most domains (except ICU admission) and the mean number of procedures received has actually grown faster among decedents. Furthermore, although fewer beneficiaries die in an acute care hospital now than in the past, those who do are being treated more intensively and expensively. We cannot know whether observed trends in inpatient treatment intensity would have been different had Medicare-financed alternatives such as hospice and home health care not been introduced during this time period. However, given the secular trends we document, in inpatient treatment intensity it is entirely possible that Medicare costs for the dying may have been even higher than they are now had there been no alternatives to hospital-based death.