Demographics and Associated Costs of Dying for Enrolled Veterans Preliminary Findings James Breckenridge, PhD James Hallenbeck, MD Co-Principal Investigators VA Palo Alto HCS

Questions Driving Study Why do people die where they do? Why do people die where they do? What explains patterns of variance in venue of death? What explains patterns of variance in venue of death? What patient-specific and what system variables affect these patterns? What patient-specific and what system variables affect these patterns? How do costs vary by venue of death How do costs vary by venue of death What accounts for cost differences What accounts for cost differences

Co-Investigators Susan Ettner, PhD, UCLA Susan Ettner, PhD, UCLA Karl Lorenz, MD, West LA VAMC Karl Lorenz, MD, West LA VAMC This project is funded by a grant from the Robert Wood Johnson Foundation

Questions for the VA Should the VA invest in palliative care? Should the VA invest in palliative care? Is such care “cost-effective”? Is such care “cost-effective”? Could adequate dollars be cost-shifted or avoided to justify such an investment? Could adequate dollars be cost-shifted or avoided to justify such an investment? Why is there such variance across VA regions and facilities? Why is there such variance across VA regions and facilities? Is palliative care is luxury the VA cannot afford, or can the VA not afford not to have palliative care?

Questions beyond VA To what extent do any cost savings made possible through the provision of palliative care result from referral biases and to what extent do they result from systems of care provided? To what extent do any cost savings made possible through the provision of palliative care result from referral biases and to what extent do they result from systems of care provided? To what extent are known geographic variations in end-of-life care in the Medicare world similar or different in the VA? To what extent are known geographic variations in end-of-life care in the Medicare world similar or different in the VA? Corollary: Are geographic variations immutable or can a different system of care influence these patterns? Corollary: Are geographic variations immutable or can a different system of care influence these patterns?

Veteran Deaths – Basic Facts 29% of Americans dying each year are veterans 29% of Americans dying each year are veterans The majority of veterans are not enrolled for by care by the VA The majority of veterans are not enrolled for by care by the VA A majority of enrolled veterans do not die in VA facilities A majority of enrolled veterans do not die in VA facilities For veterans who do die in a VA facility, remarkable heterogeneity exists as to where they die and how much it costs For veterans who do die in a VA facility, remarkable heterogeneity exists as to where they die and how much it costs

Annual Veteran Deaths A small percentage of veterans die as inpatients in VA facilities

Patient Demographics VA Inpatient Deaths 47% over age 75 47% over age 75 45% married 45% married Median annual income < $10,000 Median annual income < $10,000 25% no reported income 25% no reported income 35% Service Connected 35% Service Connected Many veterans dying as inpatients have poor social support structures

Methodology Identify relevant population for analysis: All veterans during FY with at least one institutional stay: 805,311 individuals Identify relevant population for analysis: All veterans during FY with at least one institutional stay: 805,311 individuals From this population identify those veterans who died during this time period: 148,122 (18%) From this population identify those veterans who died during this time period: 148,122 (18%) Identify last institutional venue: Identify last institutional venue: ICU, Acute Care (non-ICU), Nursing Home, Other, Dedicated Palliative Care Bed ICU, Acute Care (non-ICU), Nursing Home, Other, Dedicated Palliative Care Bed Analyze associated demographics and costs Analyze associated demographics and costs

Please note: these results reflect preliminary data – results subject to ongoing data validation DO NOT CITE

Patients dying during last institutional stay 79, 216 (53% ) died in an institutional setting at some time over three year period 79, 216 (53% ) died in an institutional setting at some time over three year period

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

Cost per Day and Average LOS AverageMedian Average LOS Additional Days ICU$1624$ acute Acute$641$ ICU NHC$253$ PalliativeCare$278$26224

What if… Dying patients were redistributed among ICU, Acute and Nursing Home venues such that: Dying patients were redistributed among ICU, Acute and Nursing Home venues such that: Percentage dying in ICU = % dying in ICUs under Medicare: 16.9% of acute care deaths Percentage dying in ICU = % dying in ICUs under Medicare: 16.9% of acute care deaths The ratio of nursing home to acute care deaths became 2:1. (Predicated within 30 years nationally by experts such as Joan Teno) The ratio of nursing home to acute care deaths became 2:1. (Predicated within 30 years nationally by experts such as Joan Teno) No change in cost per day per venue or LOS for dying patients No change in cost per day per venue or LOS for dying patients

Theoretical Cost Savings with Better Patient Distribution 5382 patients per year currently dying in acute care would need to be transferred to nursing homes

Annual Cost Savings to VA with Redistribution $40,494,886 –assuming redistribution into new nursing home beds at $253 per day

What if these patients went into dedicated palliative care beds and this utilization replaced existing NH workload? Only incremental cost would be the difference in cost between a non-hospice NH bed per day (approximately $220/day and a dedicated palliative care bed $278/day (3.2 million/year) * Only incremental cost would be the difference in cost between a non-hospice NH bed per day (approximately $220/day and a dedicated palliative care bed $278/day (3.2 million/year) * Using these values annual VA savings: ~ $48,000,000/year Using these values annual VA savings: ~ $48,000,000/year The estimated 54,435 BDOC annually these veterans would use would be approximately 1.3% of 4.3 million annual BDOC in VA nursing homes The estimated 54,435 BDOC annually these veterans would use would be approximately 1.3% of 4.3 million annual BDOC in VA nursing homes *Not counting any possible CNH or Fee Basis resulting from possible shift in workload

ICU Terminal Stay ICD9 Codes Diagnosis Freq % Diagnosis Freq % Diagnosis Freq %

Acute Care Terminal IC9 Codes Diagnosis Freq %

Nursing Home Terminal ICD9 Codes Diagnosis Freq %

Patients in Dedicated Palliative Care Beds TAPC Survey identified 37 facilities with dedicated beds or units TAPC Survey identified 37 facilities with dedicated beds or units To date have full SSNs from 22/37 (59% of TAPC respondents) To date have full SSNs from 22/37 (59% of TAPC respondents) These units in combination reported 233 beds/384 total beds reported in this category (61% of such beds) These units in combination reported 233 beds/384 total beds reported in this category (61% of such beds) 3896 patients identified to date 3896 patients identified to date

Dedicated Palliative Care Beds Average Cost per day: $278 Average Cost per day: $278 Average Length of Stay: 24 days Average Length of Stay: 24 days Total direct cost for three years: $25,386,135 Total direct cost for three years: $25,386,135 Of 3724 matched in our database:

Projected Number in Dedicated Beds and Associated Costs Assuming surveyed programs were representative of programs not surveyed: Assuming surveyed programs were representative of programs not surveyed: Estimated number of veterans dying in dedicated beds: 6,330 over three years Estimated number of veterans dying in dedicated beds: 6,330 over three years Estimated direct cost of such care over three year period: $41,000,000 Estimated direct cost of such care over three year period: $41,000,000

Dedicated Palliative Care Bed ICD9 Codes Diagnosis Freq % Diagnosis Freq % Diagnosis Freq %

Of top 50 Palliative Care ICD 9 Codes 73% cancer Diagnoses 73% cancer Diagnoses 8% unclear as to actual diagnosis 8% unclear as to actual diagnosis 19% Non-cancer diagnoses 19% Non-cancer diagnoses

Non-cancer Diagnoses: Of 2513 codes (67% of sample) total # with the following diagnoses over 3 years Are non-cancer diagnoses under-represented in VA dedicated PC programs?

Direct Costs of Care for Last Six Months and Last Year of Life Institutional Costs Outpatient & Fee Costs Total Direct Costs Six Months $743,162,000$159,604,000$902,766,000 OneYear$966,439,000$204,832,000$1,172,237,000

VA Cost per Veteran for Last Year of Life Direct Cost: $27,798 per veteran With est. 37% indirect cost: $44,124 per veteran Comparison: Medicare Claims Data age 65-74: $31,800 /year Hogan et al. Health Affairs 2001, based on 1997 claims data ESTIMATED DIRECT AND INDIRECT COST: $1,749,608,000

What percent of the VHA Budget is Spent on the Last Year of Life? Of approximately $17,000,000,000 allocated per year by VHA for clinical care over, 10% is for care in the last year of life

Patients not Dying in VA Facilities Less known about where these veterans die Less known about where these veterans die What are “risk factors” for dying in a VA facility vs. outside? What are “risk factors” for dying in a VA facility vs. outside? Diagnosis Diagnosis Socioeconomic variables Socioeconomic variables Distance from VA facility Distance from VA facility Facility characteristics Facility characteristics

Deaths with 30 days and > 30 days post discharge Cumulative deaths by last venue

ICD9 Codes for patients dying within 30 days of an acute care admit N=16,560 Diagnosis Freq % Diagnosis Freq % Diagnosis Freq %

Future Work Cost comparison analysis, using techniques such as instrumental variables and propensity scores Cost comparison analysis, using techniques such as instrumental variables and propensity scores Break down of data by VISN and individual facilities, creating “score cards” on key indicators Break down of data by VISN and individual facilities, creating “score cards” on key indicators More detailed analysis of “risk factors” for dying in certain venues and categories More detailed analysis of “risk factors” for dying in certain venues and categories More detailed examination of transitions among venues More detailed examination of transitions among venues