Is there disparate support for end-of-life care?

Data from California ICUs say there is

Some critical care physicians have argued that patients enrolled in Medicare HMOs are less likely than their fee-for-service counterparts to receive "unnecessary" and expensive end-of-life care. Now a California study supports that claim.

Researchers at the Veterans Affairs Palo Alto (CA) Health Care System compared billing records of more than 80,000 Medicare patients in ICUs from 1994 among several California hospitals.1

"The [Medicare HMOs] organizations appear to use critical care services more judiciously near the end of life, presumably lowering the costs of care," says Daniel J. Cher, MD, a primary researcher at Palo Alto. Patients enrolled in Medicare HMOs were 25% less likely than their counterparts to receive potentially ineffective care, Cher says.

Ineffective care was defined as prolonged, high-intensity medical treatment and short-term death. Conversely, almost 5% of the fee-for-service patients received potentially ineffective care and used more than 21% of the ICU resources for the year studied. (See chart, p. 95.)

"Based on anecdotal results from ongoing studies, there's evidence that patients in Medicare HMO plans choose less expensive care when presented with all the available options," says Andrew Webber, senior associate for quality policy at the Washington, DC-based Consumer Coalition for Quality Health Care.

The American Association of Health Plans, however, says its research finds there are similar levels of care. "The new data once again confirm that health plan members receive care tailored to the individual needs of each patient," says Karen Ignagni, president and CEO of the Washington, DC-based group. The association's analysis compared HMO and fee-for-service lengths of stay for conditions selected by the American College of Surgeons for two measurements.

The first measurement is a range of length of stays identified as appropriate by College of Surgeon members. The second is based on a set of optimal recovery guidelines developed by Seattle-based Milliman and Robertson, an actuarial company. Data were provided by the Medstat Group in Ann Arbor, MI.

The patients themselves might settle the debate once and for all, says Webber ."The mantra we keep preaching is to support the patients and let them address the issue directly. Let patients decide how they want to leave the world." Informing patients about the importance of advance directives early in a hospitalization is one way to determine their preferences, says Webber. Involving a patient's family members also is important so that they hear those preferences, he adds.


1. Cher D, Lenert L. Method of Medicare reimbursement and the rate of potentially ineffective care of critically ill patients. JAMA1997; 278:1,001-1,007.