BACKGROUND/RATIONALE:
The veteran population is aging rapidly. The number of veterans aged 85 and older grew from 223,000 in 1995 to 980,000 in 2005. However, little is known about the overall level of healthcare utilization near the end-of-life care at the VA. Because VA has broader service coverage and a different reimbursement structure than Medicare, findings from Medicare population may not be extended to VA for policy consideration. Looking more closely at VA patients at the end of life can also tell us about Medicare utilization and costs among dual eligible veterans approaching death.
OBJECTIVE(S):
In this study, we analyzed medical care costs and utilization patterns of five selected medical treatments in both VA and Medicare facilities during the final 2 years of life of elderly VA patients. We examined aggressiveness of care by cause of death as well as variations due to age, race and geographic region.
METHODS:
We performed a retrospective analysis of healthcare utilization in the last 2 years of life using VA and Medicare administrative files. The study included all VA patients who died in FY2000 and FY2001 (N=149,307). We analyzed costs and patterns of resource use by type of medical service provided and cause of death. We measured VA costs and expenses of Medicare services. We also investigated five aggressive hospital services (selected by a physician panel in a previous study): intensive care stays, mechanical ventilator use, pulmonary artery monitor use, dialysis and cardiac catheterization. We examined the use of these aggressive hospital services at different time intervals to determine if their use declines before death. We analyzed whether there were systematic differences in aggressiveness of care for different age and race groups or across the 21 VA integrated service networks. Multivariate regression was used to control for factors associated with patients, facilities, and geographic regions.
FINDINGS/RESULTS:
Overall costs and types of services.
Totaling both VA and Medicare benefits, elderly veterans incurred an average of $43,795 in the final year of life, 40% more than an average Medicare beneficiary accrued during the final year of life. Costs for elderly veterans started increasing rapidly in the final year of life and accelerated sharply during the final 90 days of life. Most of the cost increase near the end of life was for acute hospital services; acute hospital care accounted for 44% and 60% in year 2 and year 1 before death, respectively, and 78% in the final 30 days of life.
Influences of age and race.
Costs declined with increasing age at death. Conservativeness in medical care with respect to increasing in age was also reflected by an increased use of other (non-acute) inpatient care and a decreased use of acute hospital care at the end of life. After controlling for demographic, regional, and clinical factors, the total costs in the final year of life declined 6.9% between the 67-74 age group and the 75-84 group, and 20.8% between the 67-74 group and the 85 plus age group. The selected aggressive medical treatments were more conservatively used as the veterans aged. The rates of the selected aggressive medical treatments among acute hospital stays declined with increasing in age in both bivariate and multivariate analyses.
Black veterans incurred approximately 18% more costs than white veterans and other minority veterans, even after adjustting for age, gender, region, cause of death, and comorbid conditions. We found a mixed pattern of aggressive treatment usage across the three major race groups. Compared to white veterans, black veterans were more likely to use mechanical ventilators and dialysis, but less likely to use cardiac catheterization and pulmonary artery monitors; they had similar levels of ICU use as white veterans.
Variation by VISN. Resource use near the end of life varied substantially across VISNs. The total cost in the final year of life in the VISN with the highest costs was almost 50% higher than that of the VISN with the lowest costs even after adjusting for age, race, gender, cause of death, and comorbid conditions. The variations in use of the five selected medical treatments among acute hospital stays were more significant in raw statistics than those identified by multivariate regressions.
Aggressiveness of medical treatments near death.
The data showed rational use of the selected aggressive medical treatments with respect to medical condition. For patients who died of cancer, the use of aggressive medical treatments declined in the final year of, life except during the final 30 days when there was a slight increase in the utilization of aggressive medical treatments.
IMPACT:
This study provides three policy considerations. First, the substantial use of Medicare services during the final 24 months of life raises the importance of collaboration between VA and CMS to improve access to care and continuity of care, especially for patients near the end of life. Second, the large differences in resource use during the final year of life between VISNs require further investigation to see if medical resources could be reallocated so that both efficiency and patients’ satisfaction could be improved. Third, variations in Medicare use have a direct economic impact on each VISN. Whether the VA budget should adjust for Medicare contributions at the VISN level deserves further evaluation.
PUBLICATIONS:
Journal Articles
- Richardson SS, Sullivan G, Hill A, Yu W. Use of aggressive medical treatments near the end of life: differences between patients with and without dementia. Health Services Research. 2007; 42(1 Pt 1): 183-200.
- Yu W, Ravelo A, Wagner TH, Barnett PG. The relationships among age, chronic conditions, and healthcare costs. American Journal of Managed Care. 2004; 10(12): 909-16.
- Emanuel EJ, Ash A, Yu W, Gazelle G, Levinsky NG, Saynina O, McClellan M, Moskowitz M. Managed care, hospice use, site of death, and medical expenditures in the last year of life. Archives of Internal Medicine. 2002; 162(15): 1722-8.
- Levinsky NG, Yu W, Ash A, Moskowitz M, Gazelle G, Saynina O, Emanuel EJ. Influence of age on Medicare expenditures and medical care in the last year of life. JAMA : The Journal of The American Medical Association. 2001; 286(11): 1349-55.
- Baine WB, Yu W, Summe JP. Epidemiologic trends in the hospitalization of elderly Medicare patients for pneumonia, 1991-1998. American Journal of Public Health. 2001; 91(7): 1121-3.
- Baine WB, Yu W, Weis KA. Trends and outcomes in the hospitalization of older Americans for cardiac conduction disorders or arrhythmias, 1991-1998. Journal of The American Geriatrics Society. 2001; 49(6): 763-70.
