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 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.
In this study, we analyzed costs and aggressiveness of care for elderly veterans during their final two years of life in both VA and Medicare facilities by age, race and geographic region.
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.
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 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 adjusting for age, gender, region, cause of death, and comorbid conditions. 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.
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.
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.
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- 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 Aug 12; 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 Sep 19; 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 Jul 1; 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 Jun 1; 49(6):763-70.
- Yu W, Richardson S, Chow A, Hill A, Garber AM. Variations of aggressive medical treatments in VA and Medicare hospitals. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 25; Seattle, WA.
- Yu W, Richardson S, Chow A, Hill A, Garber AM. Variations across VISNs in the end-of-life medical treatment and cost. Paper presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA.
- 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. Paper presented at: Society of General Internal Medicine California / Hawaii Regional Annual Meeting; 2005 Oct 21; San Francisco, CA.
- Richardson S, Yu W. Controlling for patient case mix at the end of life: Issues in identifying cause of death. Poster session presented at: AcademyHealth Annual Research Meeting; 2005 Jun 1; Boston, MA.
- Yu W, Hill A, Richardson S, Garber A. Regional Variations of Aggressive Medicare Treatments in VA and Medicare Hospitals. Poster session presented at: AcademyHealth Annual Research Meeting; 2005 Jun 1; Boston, MA.
Health Systems, Aging, Older Veterans' Health and Care
Epidemiology, Treatment - Observational