Multiple chronic conditions may have large impact on national end-of-life spending, study says

Americans with multiple chronic conditions -- not necessarily those with a poor immediate prognosis -- could have the largest impact on national spending, according to a new study published by Health Affairs.

Utilizing administrative claims data for older Medicare beneficiaries who died in 2012, researchers identified four standout trajectories of spending in the last year of life, labeling them "high persistent," "moderate persistent," "progressive," and "late rise spending."

Nearly half of the 99,848 decedents studied were classified as having high persistent spending in the last year of life. This category entails healthcare spending which starts off high and increases steadily during that final year. About 10 percent of those studied exhibited a progressive pattern, in which spending started off relatively low but increase steeply throughout the time period.

Moderate persistent spending, meanwhile, accounted for 29 percent of decedents and entails moderately high spending initially, followed by a brief dip, and then an increase during the last four months of life. A little over 12 percent of study subjects exhibited late rise spending; spending was very low up to four months before death, and then increased exponentially.

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Among those with the same health condition, the percentage of decedents in each spending trajectory varied little. But researchers noticed large differences when examining them by the total number of conditions. People with fewer conditions -- either one or none -- experienced late rise and moderate persistent spending, compared to those with four or more conditions. Patients with two to three conditions had the highest proportion of progressive spending, while those with four or more conditions comprised the largest proportion of high persistent spending.

There was substantial variation of absolute dollars of Medicare spending in the last year of life across the four spending trajectories. The high persistent spenders had significantly greater spending than those in other trajectories; for instance, the median total Medicare spending among that group was $59,394, compared to $37,036 among progressive spenders. Late rise spenders had the steepest curve, but substantially lower total Medicare spending in the last year of life compared to the other trajectories, with median spending of $11,166. Total Medicare spending per enrollee was strongly associated with the percentage of decadents in the high persistent spenders category.

Compared to people in other trajectories, high persistent spenders had greater use of all health services except hospice during that final year. Researchers said it was notable that they logged about twice the number of outpatient visits to specialists a higher number of inpatient days and more days in skilled nursing facilities.

Progressive spenders, meanwhile, exhibited some similarities to high persistent spenders in terms of use of inpatient health services, but were most likely to use hospice. Late rise spenders had much lower use of both inpatient and outpatient services, while high persistent spenders were more likely to have used life-prolonging treatments such as feeding tubes and mechanical ventilation.

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Accounting for nearly half of all Medicare spending, inpatient services are often targeted for reduction by moving people toward more palliative settings, researchers said. But efforts to reduce the reliance on on costly inpatient and intensive services only in the last few months of life would likely have less effect on overall costs than might be anticipated, they said.

The association of high persistent spending with having four or more chronic conditions provides a clue about where more effective strategies might be implemented, authors claimed. People in the high spending trajectory also used more ambulatory health services, including both primary care and specialty visits. The high frequency of these visits affords the potential for intervening upstream of the hospital among people with multiple conditions and at risk of death.

Among these people, who have a high burden of chronic illness and functional impairment, it might be harder for patients, families and providers to recognize when a final turn for the worse is occurring, authors said. They suggest that improving care coordination, fragmentation across providers and linkages to supportive services for these beneficiaries in general over a longer time span -- instead of focusing solely on the last months of life -- might improve the care experience and, reduce overall cost and reliance on inpatient services.

Future strategies directed at meeting the care needs of older adults with multiple chronic conditions -- not necessarily of those with a poor immediate prognosis -- could have the largest impact on national spending, the authors concluded.

Twitter: @JELagasse