Skip to main content

Functional Status and Medicare Costs in the Last 6 Months of LIfe

A large proportion of healh care costs is incurred towards the end of life. However, very little is known about how patient characteristics impact of end of life costs.

A recent study in the Annals of Internal Medicine by Dr. Amy Kelley a Geriatrician in the Mount Sinai Department of Geriatrics and Palliative Medicine is a major advance in our understanding of costs of care at the end of life. This study provides the best data yet available about how patient characteristics impact Medicare expenditures in the last 6 months of life. The study examined these costs in decedents in the landmark Health and Retirement Study.

The most important finding of this study is the tremendous importance of functional status as a determinant of end of life medical costs. Kelley showed that both the degree of functional impairment and the slope of functional decline were strong determinants of medical costs. In particular:

  • Decedents who needed no help with activities of daily living in the last 3 months of life had the lowest costs
  • Those who had moderate functional impairment (need for help in 1 to 3 activities of daily living) though the last year of life had end of life Medicare expenditures that were 20% higher than those who needed no ADL help.
  • Those who started out with good function (no need for help in activities of daily living 1 year prior to death) but has severe functional deficits in the last 3 months of life (need for help wiht 4 or more activities of daily living) had end of life Medicare expenditures that were 64% higher than those who needed no ADL help.
This study proves that functional impairment is a crucial determinant of end of life health costs. It strongly suggests that we need to pay at least as much attention to patients' functional status as we pay to their diagnoses. As noted by the authors:

"Healthcare reforms may have a greater effect on improving care and reducing costs if they prioritize patient-centered rather than single disease oriented models of care. These efforts should include high-quality primary care and well-coordinated care for these complicated and functionally impaired patients."

by: Ken Covinsky


Patrice Villars said…
This is another great example of the important intersection between geriatrics and palliative care. Health care costs would very likely be lowered. Elderly patients and their families would be much better served if all older adults with decreasing functional status had automatic and easily accessible palliative care.
hyperhydrosis said…
The most important finding of this study is the tremendous importance of functional status as a determinant of end of life medical costs. Health care costs would very likely be lowered.
Good article summarizing study results. Because of the scope of Medicare, it might be difficult to determine topics such as a patients' functionality.
Dan Matlock said…
This was a super article by Amy Kelly wt al.

A huge challenge in this disucssion is finding a distinction between appropriate and inappropriate variations in end-of-life spending. That is, for years, Dartmouth has demonstrated wide variation in end-of-life spending by region. This article showed that this variation remained significant even after adjustment for a host of patient variables. This strengthens the arguement that regional variations are "inappropriate" as they don't relate to patient variability.

This is another extremely important contribution of this article as the Dartmouth Atlas has received so much criticism for their inability to adjust for patient variability.
Dr. Rob said…
This was a very detailed and concise article on the functionality of patients toward the end of their life. It was eye opening.

I recently came across a study published in Topics in Clinical Chiropractic, The study consisted of randomized clinical trial data and found chiropractic geriatric patients "less likely to have been hospitalized, less likely to have used a nursing home, more likely to report a better health status, more likely to exercise vigorously, and more likely to be mobile in the community."

This study suggests that chiropractic may aid in the functionality of geriatrics towards the end of their life.

Popular posts from this blog

Lost in Translation: Google’s Translation of Palliative Care to ‘Do-Nothing Care’

by: Cynthia X. Pan, MD, FACP, AGSF (@Cxpan5X)

My colleagues often ask me: “Why are Chinese patients so resistant to hospice and palliative care?” “Why are they so unrealistic?” “Don’t they understand that death is part of life?” “Is it true that with Chinese patients you cannot discuss advance directives?”

As a Chinese speaking geriatrician and palliative care physician practicing in Flushing, NY, I have cared for countless Chinese patients with serious illnesses or at end of life.  Invariably, when Chinese patients or families see me, they ask me if I speak Chinese. When I reply “I do” in Mandarin, the relief and instant trust I see on their faces make my day meaningful and worthwhile.

At my hospital, the patient population is about 30% Asian, with the majority of these being Chinese. Most of these patients require language interpretation.  It becomes an interesting challenge and opportunity, as we often need to discuss advance directives, goals of care, and end of life care options…

Elderhood: Podcast with Louise Aronson

In this week's podcast we talk with Louise Aronson MD, MFA, Professor of Geriatrics at UCSF about her new book Elderhood, available for purchase now for delivery on the release date June 11th.

We are one of the first to interview Louise, as she has interviews scheduled with other lesser media outlets to follow (CBS This Morning and Fresh Air with Terry...somebody).

This book is tremendously rich, covering a history of aging/geriatrics, Louise's own journey as a geriatrician facing burnout, aging and death of family of Louise's members, insightful stories of patients, and more.

We focus therefore on the 3 main things we think our listeners and readers will be interested in.

First - why the word "Elder" and "Elderhood" when JAGS/AGS and others recently decided that the preferred terminology was "older adult"?

Second - Robert Butler coined the term ageism in 1969 - where do we see ageism in contemporary writing/thinking?  We focus on Louise's…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …