Going Below the Surface E-newsletter: July 2018
July 25, 2018
It’s our second edition of Going Below the Surface, where each month we’re digging deep on how well we are spending our health care dollars in the United States. This month, we’re probing difficult topics such as spending on end of life care, considering budget thresholds and financing curative therapies. We encourage you to share, subscribe and follow us between issues using #GoingBelowTheSurface.
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Spending on End of Life Care
This idea that too much money is spent on patients who are at the end of their life is considered conventional wisdom in health policy. But as with so much in health care, that’s a simplistic notion, as two nuanced peer-reviewed studies in the past few weeks demonstrated.
Science published a study June 29 that found 95 percent of Medicare spending is actually for patients who were expected to survive one year or longer. Furthermore, the analysis–which tracked nearly 6 million patients–found that of the patients who were considered likely to die within one year, nearly half lived longer. These findings suggest that we should limit our focus to figuring out how to optimize care for sick patients, irrespective of their prognosis.
Adding another layer of complexity to the topic is an article from the July issue of Health Affairs that found substantial variation in end of life spending for cancer patients across geographies. Noteworthy was the finding that geographic variation in spending during the last 30 days of a cancer patient’s life is largely driven by physicians’ beliefs (e.g., attitudes about hospice or whether they felt knowledgeable or comfortable treating dying patients) and the availability of health care services within different hospital referral regions, not patient preferences.
Why It Matters: The evidence identifies areas to explore. Rather than predicting who will die soon, perhaps the focus should be more generally on the very sick patients and what care is high value and what is not. Why do physicians’ beliefs have an outsized impact on spending at the end of a cancer patient’s life? How can we train physicians to be more comfortable in these end of life interactions or provide more education about hospice care? Read more here from NPC Chief Science Officer Robert W. Dubois, MD, PhD, on confronting misconceptions in end of life spending.
Why We Need to “Go Below The Surface” to Consider Medicare and Medicaid Spending
The number of Americans who are 65 years of age or older and their use of health care services are continuing to increase: inflation-adjusted Medicare spending is expected to increase by 5.33 percent annually between 2016 and 2026, with nearly half of the growth due to increases in the number of beneficiaries, according to Centers for Medicare and Medicaid Services’ projections. Similar trends are expected in Medicaid.
In a recent New England Journal of Medicine article, researchers examine four potential solutions:
As the researchers discuss, all of these solutions have serious downsides. Increasing costs would end up reducing access to care and exacerbate health disparities. Encouraging the use of preventive services might be cost effective but not cost saving. Relying on private health plans has had mixed results but requires government efficiency. And while recent evidence suggests that alternative payment models can reduce spending, effects are generally small.
Why It Matters: Potential or immediate solutions might not be politically feasible or would have serious downsides. That’s why it’s important now more than ever to have a dialogue about health spending and dig deeper into the kinds of creative solutions that could work.
New studies are showing us that health care spending is continuing to increase—is there a limit to how much we can or should spend? Some organizations and countries have set budget thresholds, requiring them to take creative approaches or make trade-offs about how they spend their limited resources. This month, we’re highlighting journal articles that take a deeper look at health spending and the challenges in making difficult choices.
Health care spending conversations are taking place across the country at events, online and around water coolers. We’ve flagged a few conversations for your attention and hope that you’ll also engage with the discussion online via #GoingBelowTheSurface.
About Going Below the Surface
The Going Below the Surface initiative was launched by the National Pharmaceutical Council in 2018 to broaden and improve the conversation around how health care resources are used in the United States. The initiative is aimed at better understanding the roots of the nation’s health spending and investments by promoting a discussion that is firmly based in health policy and systems research. Our goal is to provide clarity on how best to optimize health care spending so that patients receive the right care while simultaneously providing the right incentives to sustain next-generation innovation to improve patient well-being and health system efficiencies. To view the Going Below the Surface partners, visit www.goingbelowthesurface.org.
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