End-of-Life Care End-of-Life Care in the in the

Department of Department of Veterans AffairsVeterans Affairs

Jon Fuller, MDJon Fuller, MD

James Hallenbeck, MDJames Hallenbeck, MD

James Breckenridge, PhDJames Breckenridge, PhD

VA Palo Alto HCSVA Palo Alto HCS

PurposePurpose

Discuss recent mandates related to end-Discuss recent mandates related to end-of-life care in the VAof-life care in the VA

Present recent data showing where Present recent data showing where veterans die and how much this costsveterans die and how much this costs

Suggest ways facilities can come into Suggest ways facilities can come into better compliance with mandates, save better compliance with mandates, save money through cost-shifting and money through cost-shifting and facilitate better carefacilitate better care

Key PointsKey Points

Veterans are dying in record numbersVeterans are dying in record numbers End-of-life care as currently provided End-of-life care as currently provided

is very expensive is very expensive Too many veterans are dying in ICUs Too many veterans are dying in ICUs

and acute careand acute care Too few veterans are receiving good Too few veterans are receiving good

end-of-life care in dedicated palliative end-of-life care in dedicated palliative care beds or home hospicescare beds or home hospices

Shifting patients into better, less Shifting patients into better, less expensive venues of care can save expensive venues of care can save moneymoney

Questions for VA Questions for VA FacilitiesFacilities

Should the VA invest more in Should the VA invest more in palliative care?palliative care?

Is such care “cost-effective”?Is such care “cost-effective”? Could adequate dollars be cost-Could adequate dollars be cost-

shifted or avoided to justify such an shifted or avoided to justify such an investment? investment? Is palliative care a

luxury the VA cannot afford, or can the VA not

afford not to have palliative care?

FANTASY DEATH FANTASY DEATH EXERCISEEXERCISE

Mandates and other Mandates and other PressuresPressures

Millennium BillMillennium Bill Palliative Care Consult Memorandum Palliative Care Consult Memorandum Call for dedicated Palliative Care Beds Call for dedicated Palliative Care Beds

(GEC Strategic Plan, National Policy (GEC Strategic Plan, National Policy Board 2/12/02)Board 2/12/02)

Lots of very sick and dying veterans on Lots of very sick and dying veterans on your doorstepyour doorstep ICU and acute care bed pressureICU and acute care bed pressure

Not enough money…Not enough money…

Good News!Good News!

Shifting workload out of acute care into Shifting workload out of acute care into dedicated palliative care beds, HBPC or dedicated palliative care beds, HBPC or community hospices can:community hospices can: Help you meet Millennium Bill targetsHelp you meet Millennium Bill targets Meet evolving mandates for palliative care Meet evolving mandates for palliative care

servicesservices Save you moneySave you money Increase high VERA reimbursementIncrease high VERA reimbursement Create excellent PR for your facility Create excellent PR for your facility Help veterans exercise choice in where and how Help veterans exercise choice in where and how

they diethey die

Veteran Deaths – Basic Veteran Deaths – Basic FactsFacts

29% of Americans dying each year 29% of Americans dying each year are veteransare veterans

The majority of dying veterans are not The majority of dying veterans are not enrolled for by care by VAenrolled for by care by VA

A majority of enrolled veterans do not A majority of enrolled veterans do not die in VA facilitiesdie in VA facilities

A small shift of very sick and dying A small shift of very sick and dying veterans not currently served by VA veterans not currently served by VA into the VA could swamp the systeminto the VA could swamp the system

Annual Veteran Annual Veteran DeathsDeaths

A small percentage of veterans die as inpatients in VA facilities

National VA Mortality by VISN FY2000

0

500

1000

1500

2000

2500

3000

VISN

# Dea

ths b

y Loc

ation VAMC Total Deaths

Hospital Deaths

Nursing Home Deaths

Demographics and Demographics and Associated Costs of Dying for Associated Costs of Dying for

Enrolled VeteransEnrolled VeteransPreliminary FindingsPreliminary Findings

James Breckenridge, PhDJames Breckenridge, PhD

James Hallenbeck, MDJames Hallenbeck, MD

Co-Principal InvestigatorsCo-Principal Investigators

VA Palo Alto HCSVA Palo Alto HCS

Susan Ettner, PhD, UCLA, Susan Ettner, PhD, UCLA,

Karl Lorenz, MD, West LA VA Karl Lorenz, MD, West LA VA

- Co investigators - Co investigators Preliminary data Preliminary data – do not cite– do not cite

Funded by the Robert Funded by the Robert Wood Johnson Wood Johnson

FoundationFoundation

Dying Veterans over 3 Dying Veterans over 3 Fiscal YearsFiscal Years

Identified 148,122 veterans who died Identified 148,122 veterans who died nationwide, who had at least 1 nationwide, who had at least 1 inpatient stayinpatient stay

Identified last inpatient stay:Identified last inpatient stay: ICU, Acute Care (non-ICU), Nursing ICU, Acute Care (non-ICU), Nursing

Home, Other, Dedicated Palliative Care Home, Other, Dedicated Palliative Care Bed Bed

Calculated how many veterans died, Calculated how many veterans died, associated costs and related statisticsassociated costs and related statistics

Patients dying during Patients dying during last institutional staylast institutional stay

79, 216 (53% )79, 216 (53% ) died in an died in an institutional setting at some time institutional setting at some time over three year periodover three year period

27%

38%

17%

8%

10% ICU Deaths

Acute Care Deaths

NHC Deaths

Ded. Palliative Care BedDeaths (est)

Deaths in Other Setting

41%41% of VA acute care deaths of VA acute care deaths in ICU as compared to in ICU as compared to 16.9%16.9%

under Medicare…under Medicare…

Costs of Terminal StaysCosts of Terminal Stays

Percentage total cost by venue

38%

29%

18%

4%

11%ICU Deaths

Acute Care Deaths

NHC Deaths

Ded. Palliative CareDeaths

Other Setting

Annual direct cost of terminal admits:Annual direct cost of terminal admits: $387,367,000$387,367,000

67% of costs in acute care67% of costs in acute care

Cost per Day and Cost per Day and Average LOSAverage LOS

AveragAveragee

MedianMedian AveragAverage LOSe LOS

AdditioAdditional nal DaysDays

ICUICU $1624$1624 $1406$1406 10.710.7 3.4 3.4 acuteacute

AcuteAcute $641$641 $536$536 10.310.3 2.1 ICU2.1 ICU

NHCNHC $253$253 $230$230 44.544.5

PalliativPalliative e

CareCare

$278$278 $262$262 2424

Average Cost Per Day for Average Cost Per Day for Terminal Stays Terminal Stays

$0$500

$1,000$1,500$2,000

ICU Acute Care NursingHome

PalliativeCare

Direct DSS CostDirect DSS Cost

ICU Deaths by VISNICU Deaths by VISN

ICU deaths as % of PTF Discharges

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

1 3 5 7 9

11

13

15

17

19

21

23

VISNs

Perc

en

tag

e IC

U d

eath

s

ICU Deaths as % General ICU Deaths as % General Medicine Unique PatientsMedicine Unique Patients

ICU Deaths as % Gen Med Uniques

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

1 2 3 4 5 6 7 8 9 10 11 1213 14 15 16 17 18 19 20 21 22 23

ICU Utilization in Last Six ICU Utilization in Last Six Months of LifeMonths of Life

Percent of PTF Unique pts with any ICU days last six months of life

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

3 Year ICU Deaths

050

100150200250300350

Facility

# of

Dea

ths

3 Year ICU Deaths

Deaths per # PTF and per ICU Beds

02468

10121416

Facility

Perc

ents

and

Rat

ios

% Unique PTF

Deaths:ICU Beds

3 Year ICU Deaths

0

50

100

150

200

250

300

350

LomaLinda

LongBeach

SanDiego

LasVegas

WestLA

Facility

# of

Dea

ths

3 Year ICU Deaths

Deaths per # PTF and ICU Beds

02468

10121416

LomaLinda

LongBeach

SanDiego

LasVegas

West LA

Facility

Perc

ents

and

Rat

ios

% PTF

Deaths:ICU Beds

VISN VISN 2121

VISN VISN 2222

Direct Costs of Care for Direct Costs of Care for Last Six Months and Last Last Six Months and Last

Year of LifeYear of LifeInstitutional Institutional

CostsCostsOutpatient Outpatient

& Fee & Fee CostsCosts

TotalTotal

Direct Direct CostsCosts

Six Six MonthsMonths

$743,162,000$743,162,000 $159,604,$159,604,000000

$902,766,$902,766,000000

One One

YearYear$966,439,000$966,439,000 $204,832,$204,832,

000000$1,172,23$1,172,23

7,0007,000

VA Cost per Veteran for VA Cost per Veteran for Last Year of LifeLast Year of Life

Estimated total VA cost per Estimated total VA cost per veteran in last year of lifeveteran in last year of life

$44,124 $44,124

Comparison: Medicare Comparison: Medicare Claims Data age 65-74: Claims Data age 65-74: $31,800 /year $31,800 /year Hogan et al. Hogan et al. Health AffairsHealth Affairs 2001, 2001,

based on 1997 claims databased on 1997 claims data

ESTIMATED DIRECT AND ESTIMATED DIRECT AND INDIRECT COST: INDIRECT COST: $1,749,608,000$1,749,608,000

What percent of the VHA What percent of the VHA Budget is Spent on the Budget is Spent on the

Last Year of Life?Last Year of Life?Of approximately Of approximately

$17,000,000,000 allocated per $17,000,000,000 allocated per year by VHA for clinical care year by VHA for clinical care

10%10%

is for care in the last year of is for care in the last year of lifelife For 1.3% of For 1.3% of

enrolled veterans…enrolled veterans…

The question is not whether or not we The question is not whether or not we shouldshould provide end-of-life care – we provide end-of-life care – we

already arealready are

The question is whether we The question is whether we are using resources wisely in are using resources wisely in

the provision of this carethe provision of this care

AndAnd

Whether or not we can honor Whether or not we can honor veterans’ preferences as to veterans’ preferences as to

where they wish to diewhere they wish to die

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

National Palo Alto Lebanon Dayton

National vs three stations with palliative care units

FY 2000 Inpatient Deaths by Location

ICU (all)

General Medicine

Intermediate Medicine

Nursing Home

Things to considerThings to consider

Develop palliative care consult teamsDevelop palliative care consult teams Identify a palliative care coordinator Identify a palliative care coordinator

to help with:to help with: Community hospice referralsCommunity hospice referrals Staff education regarding palliative care Staff education regarding palliative care

optionsoptions Liaison to the communityLiaison to the community

Develop dedicated bed programs, Develop dedicated bed programs, where not presentwhere not present

SUMMARYSUMMARY

Veterans are dying in record Veterans are dying in record numbersnumbers

End-of-life care as currently End-of-life care as currently provided is very expensive provided is very expensive

Too many veterans are dying in ICUs Too many veterans are dying in ICUs and acute careand acute care

Too few veterans are receiving good Too few veterans are receiving good end-of-life care in dedicated beds or end-of-life care in dedicated beds or home hospiceshome hospices

Shifting patients into better, less Shifting patients into better, less expensive venues of care can save expensive venues of care can save you moneyyou money