1. End-of-Life Care in the Department of Veterans Affairs Jon Fuller, MD James Hallenbeck, MD James Breckenridge, PhD VA Palo Alto HCS

2. Purpose Discuss recent mandates related to end-of-life care in the VA Discuss recent mandates related to end-of-life care in the VA Present recent data showing where veterans die and how much this costs Present recent data showing where veterans die and how much this costs Suggest ways facilities can come into better compliance with mandates, save money through cost-shifting and facilitate better care Suggest ways facilities can come into better compliance with mandates, save money through cost-shifting and facilitate better care

3. Key Points Veterans are dying in record numbers Veterans are dying in record numbers End-of-life care as currently provided is very expensive End-of-life care as currently provided is very expensive Too many veterans are dying in ICUs and acute care Too many veterans are dying in ICUs and acute care Too few veterans are receiving good end-of-life care in dedicated palliative care beds or home hospices Too few veterans are receiving good end-of-life care in dedicated palliative care beds or home hospices Shifting patients into better, less expensive venues of care can save money Shifting patients into better, less expensive venues of care can save money

4. Questions for VA Facilities Should the VA invest more in palliative care? Should the VA invest more 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? Is palliative care a luxury the VA cannot afford, or can the VA not afford not to have palliative care?

5. FANTASY DEATH EXERCISE Where and how do you wish to die?

6. Mandates and other Pressures Millennium Bill Millennium Bill Palliative Care Consult Memorandum Palliative Care Consult Memorandum Call for dedicated palliative care beds (GEC Strategic Plan, National Policy Board 2/12/02) Call for dedicated palliative care beds (GEC Strategic Plan, National Policy Board 2/12/02) Lots of very sick and dying veterans on your doorstep Lots of very sick and dying veterans on your doorstep ICU and acute care bed pressure ICU and acute care bed pressure Not enough money… Not enough money…

7. Good News! Shifting workload out of acute care into dedicated palliative care beds, HBPC or community hospices can: Shifting workload out of acute care into dedicated palliative care beds, HBPC or community hospices can: Help you meet Millennium Bill targets Help you meet Millennium Bill targets Meet evolving mandates for palliative care services Meet evolving mandates for palliative care services Save you money Save you money Increase high VERA reimbursement Increase high VERA reimbursement Create excellent PR for your facility Create excellent PR for your facility Help veterans exercise choice in where and how they die Help veterans exercise choice in where and how they die

8. Veteran Deaths – Basic Facts 29% of Americans dying each year are veterans 29% of Americans dying each year are veterans The majority of dying veterans are not enrolled for by care by VA The majority of dying veterans are not enrolled for by care by VA A majority of enrolled veterans do not die in VA facilities A majority of enrolled veterans do not die in VA facilities A small shift of very sick and dying veterans not currently served by VA into the VA could swamp the system A small shift of very sick and dying veterans not currently served by VA into the VA could swamp the system

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

11. Demographics and Associated Costs of Dying for Enrolled Veterans Preliminary Findings James Breckenridge, PhD James Hallenbeck, MD Co-Principal Investigators VA Palo Alto HCS Susan Ettner, PhD, UCLA, Susan Ettner, PhD, UCLA, Karl Lorenz, MD, West LA VA - Co investigators Preliminary data – do not cite Funded by the Robert Wood Johnson Foundation

12. Dying Veterans over 3 Fiscal Years Identified 148,122 veterans who died nationwide, who had at least 1 inpatient stay Identified 148,122 veterans who died nationwide, who had at least 1 inpatient stay Identified last inpatient stay: Identified last inpatient stay: ICU, Acute Care (non-ICU), Nursing Home, Other, Dedicated Palliative Care Bed ICU, Acute Care (non-ICU), Nursing Home, Other, Dedicated Palliative Care Bed Calculated how many veterans died, associated costs and related statistics Calculated how many veterans died, associated costs and related statistics

13. 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 41% of VA acute care deaths in ICU as compared to 16.9% under Medicare… 65% of terminal admits in acute care

14. Costs of Terminal Stays Annual direct cost of terminal admits: $387,367,000 67% of costs in acute care

15. Cost per Day and Average LOS AverageMedian Average LOS Additional Days ICU$1624$140610.7 3.4 acute Acute$641$53610.3 2.1 ICU NHC$253$23044.5 PalliativeCare$278$26224

16. Average Cost Per Day for Terminal Stays Direct DSS Cost

17. 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

18. VA Cost per Veteran for Last Year of Life Estimated total VA cost per veteran in last year of life $44,124 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

19. 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 10% 10% is for care in the last year of life is for care in the last year of life For 1.3% of enrolled veterans…

20. The question is not whether or not we should provide end-of-life care – we already are The question is whether we are using resources wisely in the provision of this care And Whether or not we can honor veterans’ preferences as to where they wish to die

22. Things to consider Develop palliative care consult teams Develop palliative care consult teams Identify a palliative care coordinator to help with: Identify a palliative care coordinator to help with: Community hospice referrals Community hospice referrals Staff education regarding palliative care options Staff education regarding palliative care options Liaison to the community Liaison to the community Develop dedicated bed programs, where not present Develop dedicated bed programs, where not present

23. SUMMARY Veterans are dying in record numbers Veterans are dying in record numbers End-of-life care as currently provided is very expensive End-of-life care as currently provided is very expensive Too many veterans are dying in ICUs and acute care Too many veterans are dying in ICUs and acute care Too few veterans are receiving good end-of-life care in dedicated beds or home hospices Too few veterans are receiving good end-of-life care in dedicated beds or home hospices Shifting patients into better, less expensive venues of care can save you money Shifting patients into better, less expensive venues of care can save you money