Archives for 2024

President Carter died yesterday. He had entered hospice in February 2023. Hospice, according to Medicare, is supposed to be a fairly short-ish term benefit at the end of life:

You qualify for hospice care  if you have  Medicare Part A (Hospital Insurance)  and meet all of these conditions:

• Your hospice doctor and your regular doctor (if you have one) certify that you’re terminally ill (with a life expectancy of 6 months or less).
• You accept comfort care (palliative care) instead of care to cure your illness.
• You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.

If you qualify, you can get hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods. You have the right to change your hospice provider once during each benefit period.

I do not know what health insurance a former president gets… I don’t know if they are on Medicare or something else. But let’s assume that everyone involved in the end of life journey for President Carter and his wife were acting with competence and in good faith.

If he had Medicare, he would have gone through 11 benefit periods (2 90 day periods and 9 60 day extensions). He was a massive outlier for hospice care.

This outlier status highlights a problem with a common cocktail party “analysis” that we spend too much as a society in the last 30 or 90 days of life. Those analysis have as their identification strategy a look at the death certificates of a target population and then a retrospective analysis of how much was spent on this cohort of people that we know are dead.

There is a big problem here!

At the time treatment is initiated, we as a society don’t know who is going to be dead in 30 days. Prospective prediction is HARD!

Dr. Amy Finkelstein and colleagues had a great paper at SCIENCE a few years ago with a good write up in WBUR:

Only 5 percent of people on Medicare die each year. But those who die account for a quarter of all health care spending [on seniors], and this fact […] is often talked about in the media and policy circles as evidence of waste in the U.S. health care system: “Look, we spend all this money on health care for people who die.” What a waste, right? Why are we spending money on all these people who die?

Implicit in this is the idea that, at the time we’re spending the money, we know that they’re likely to die….
In fact, we find there is very little Medicare spending on people with high probability of dying. And part of that is just that it’s very, very hard to predict who is going to die.

For example, if you take all the Medicare patients at the start of the year in the highest percentile of risk — the top 1 percent chance of dying in that year — their annual mortality rate is still only 46 percent…

Even among people admitted to the hospital who then die within one year, we still find it’s very, very hard to find a lot of people who have a very high probability of death. For example, of the people who are admitted to the hospital who then die within one year, only about 40 percent of them have a mortality probability above 50 percent.

Put another way, it’s just very hard to find a substantial share of people for whom we have very high certainty that they’re going to die within the year.

Think about people who arrive in the hospital with metastatic cancer. That’s a very sick population; that’s a very grave diagnosis. Even so, their one year annual mortality is only about two thirds, or 63 percent.

There is tremendous value in palliative care and hospice for the patient and for their family and caregivers. Perfect palliative care and hospice services would likely be a very good thing but we should not expect these services to be great at saving money because we just don’t know what people are going to die with any degree of accuracy.

Jimmy Carter, hospice and prospective predictionsPost + Comments (33)