Don't blame the dying elderly for the health-care cost crisis

Arthur Caplan

April 29, 1993|By Arthur Caplan

THERE is no agreement about what to do about the nation' hemorrhaging health-care bill. But there is a broad consensus about why health care in America costs as much as it does.

In health policy discussions all around the country, those in the know about health-care policy quietly repeat the insiders' mantra -- America spends too much money for expensive medical care on old people who are terminally ill.

The media have reinforced the belief that grandparents who are unwilling to shut off their respirators are the cause of our health-care system's fiscal woes. Story after story flits across the screen or appears on our doorstep about how much money we spend on older Americans who are in the last year, month or day of life.

While they are not always willing to say so in public, a large number of health policy gurus believe that if the health-care system could only persuade all Americans to fill out a living will or advance directive indicating that aggressive treatment ought be stopped when the prognosis is hopeless, America would no longer face a health-care cost crisis.

Sadly, the movement to encourage the use of living wills has as much to do with hopes for cost-containment as it does with self-determination.

An interesting article this month in the New England Journal of Medicine casts doubt on whether those in the know really know what they are talking about when it comes to the reasons for the high cost of health care.

James D. Lubitz and Gerald F. Riley, who are at the Health Care Financing Administration in Baltimore, the outfit that runs the federal Medicare program, believe the figures about the cost of health care for those in the last year of life are often misinterpreted or exaggerated.

Their study of the cost of medical treatment of those over age 65 in the Medicare program from 1976 to 1988 raises some very tough questions for those who think we can work our way out of the health-care cost crisis by rationing care for the terminally ill elderly.

Lubitz and Riley report that the annual number of Medicare beneficiaries went from 23.4 million in 1976 to 29.1 million in 1988. The number of those who died remained relatively stable during this period.

What is interesting is that even though the cost of the Medicare program skyrocketed from 1976, when the program cost $15 billion, to 1988, when it cost $73 billion, the percentage of the total spent on those in the last year of their lives stayed the same.

In 1976, 28.2 percent of all Medicare expenditures went to elderly people in the last year of their lives. In 1988 the number was 28.6 percent.

This means that whatever it is that is causing medical bills to go through the roof, it is not spending more and more on people in their final days.

Not only has the percentage of money spent on hospital care for those in the final year of life not grown in 12 years, Lubitz and Riley found, but also the amount of money spent on hospital care for Medicare recipients who nevertheless died was actually lower if the person died at an older age.

In 1988 the hospital bill for the last year of life for those who died at ages 65-69 was $15,436. But the bill for someone who died at ages 80-84 was $12,838. And if you were over 90 when you reached your final year on this planet, your bill was $8,888. So, the costliest Medicare patients in terms of those who ultimately die are not the oldest.

Those responsible for fixing the health-care system need to pay close attention to the Lubitz and Riley findings.

The answer to the problem of cost containment is not going to be as simple as figuring out how to cut back on hospital care for the oldest, terminally ill patients. To find the right answers, we are going to have to rid ourselves of some mythology about why health care in America costs so much.

Arthur Caplan is director of the Center for Biomedical Ethics at the University of Minnesota and a member of the Clinton administration task force on health-care reform.

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