Variations in Cost of End-of-Life Care Get a Closer Look

Two recent articles have examined the data from Dartmouth's annual Atlas of Health Care study at the local level in Massachusetts and Colorado. The first, from The Harvard Crimson, reports on some criticism of the study from Thomas H. Lee, Jr. the network president at Partners HealthCare, who owns both Mass. General Hospital and Brigham and Women’s Hospital. Lee raised the issue that data was not adjusted for differences in medical costs by state. For instance, medical professionals' wages are 20 percent higher in Massachusetts than in Minnesota (which had lower end-of-life care costs.)

Reporter June Q. Wu also interviews James B. Conway, who sits on the Mass. Health Care Quality and Cost Council. A report by the council noted that although over 70 percent of Americans say that they would prefer to die at home, only one fifth of deaths in Massachusetts were at homes in 1997. Despite legislation to increase end-of-life options, the number had only risen to 22 percent by 2005. Conway, who is a representative from the Institute for Healthcare Improvement, a non-profit organization based in Cambridge, addressed the difficulty in changing those statistics. “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.” He also stated, “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.”

As we noted in our original coverage of the Dartmouth study, hospice care was the only type of non-acute care that did not follow the variation in increased costs. A second article focusing on costs of end-of-life care in Grand Junction, Colorado appeared in today's The Denver Post. Grand Junction had one of the lower costs per patients recorded by the Dartmouth Atlas. Several factors are likely coming together to help lower these costs that involve how physicians are reimbursed and reviewed. Also helping, "Grand Junction has one well-respected, nonprofit hospice that works closely with the local medical community to provide care for those with severe chronic illnesses and to give options to those who otherwise might have to be treated and die in hospitals. Hospice caregivers attend more than half of all deaths in Mesa County."

We will continue to share new articles that refer to the Dartmouth Atlas on a local level, and we are encouraged to see some coverage now being given to the role that hospice can play in providing excellent end-of-life care.

UPDATE 4/28/08: The Miami Herald has joined in with an analysis of the Dartmouth Atlas for southern Florida. The article reports on testimony given by Peter Orszag, the director of the Congressional Budget Office, during a Senate hearing. The Herald reports on costs at six hospitals covered by the Atlas. The article noted that one of the lower cost hospitals also had a higher rate of referrals to hospice.

The report compares three Miami-Dade hospitals with high HCI scores -- Westchester, Mount Sinai and Hialeah -- with three that have much lower scores -- South Miami, Baptist and Jackson Memorial. Of these, Baptist has the lowest percentage of intensive care unit care during a final illness (25 percent) and the highest percentage admitted to hospice (46 percent), where treatment concentrates on comfort and alleviating pain.