END OF THE LINE

In 2015 a Ph.D. and MD team of researchers published a paper, "The Myth Regarding the High Cost of End-of-Life Care," that struck me as very interesting. One important component of debates on healthcare costs is the perceived high cost of treatments that do not meaningfully extend life or improve the quality of life – the perception, in other words, that doctors throw every procedure and medicine available (at patient insistence) at people who are unavoidably terminal.

The Aldridge-Kelley paper is one of just a few proper studies I've come across that characterizes it as a myth (see also this University of Michigan analysis). Their conclusion that end-of-life costs comprise about 13% of all healthcare spending and thus is not out of line with common sense expectations is contradicted by data thrown around in every healthcare policy debate I've ever seen. In fact, a Medicare study argues that end-of-life spending on healthcare is unchanged over 20 years.

This is an issue, in other words, in which we seem to be influenced heavily by anecdotal evidence ("Well, my grandmother…") and numbers sourced from groups like insurance companies or issue activists with an agenda. Of course Insurance, Inc. likes the narrative that they're forced to cover pointless procedures on dying people.

In fairness, my take on the methodology of the studies mentioned above is that they all define health care spending in a way that is likely to under-count true spending. They exclude the cost of prescription drugs, for example. The estimates they offer could reasonably be characterized as conservative. However, their underlying conclusion remains persuasive in the context of the really big medical expenditures that naturally accompany the end of life – hospitalizations, hospice or nursing home stays, major surgeries, implants, drugs administered as an inpatient, and so on.

The news item about Barbara Bush brought this point back to mind. She's 92 and has reached the point at which she and the other people involved have concluded that she's dying and medical care is futile now beyond providing palliative treatment. And really, isn't that what usually happens? How common is this straw man really, the dying person who demands putative miracle cures right up to the very end?

In some ways high end of life costs are unavoidable. That trip to the ER after a major car accident and the ten surgeries that follow are the cause of mortality and they can't be distributed throughout life. Hospice stays and hospitalizations are other examples of incredibly costly things that aren't going to happen unless…well, unless you're in failing health. And for every single one of us human beings, failing health is a process that begins at different points but always ends with death. Many of us are lucky enough that "failing health" and death are relatively proximate on our timeline. Whenever it happens, unless we die of unnatural causes, it's very likely to be expensive. Nothing about that is new.

It is worth remembering that the available data does not support the argument that end-of-life care is disproportionately expensive. A cynic might even wonder if it is yet another attempt to blame the individual for spiraling costs of the ridiculous system – "industry" is a better term, in fact – that so many Americans in positions of power seem dead-set against changing. The way people use a badly flawed system is a symptom, not a cause, of those flaws.