Health Care at an Advanced Age: Myths and Misconceptions

Cost of Dying

Consider medical expenditures in the last year of life. One of the more pervasive images clouding the health care debate is that of an extremely elderly and terminally ill patient consuming large amounts of resources shortly before he or she dies. In reality, medical expenditures in the last year of life are lower for people 80 years and older than for those in younger age groups. One study [4] of approximately 500 patients who died found that, in the last 12 months of life, those persons 80 years and older—compared with those 65 to 79 years of age and with those younger than 65 years—had only about half the hospital costs of those in younger age groups. Hospital costs per person for those who were 65 to 79 years of age were only slightly higher than those younger than 65 years in the last 12 months of life [4]. Physician costs in the last year of life were also lower for the oldest group. Of the 2 150 466 persons who died in 1989 in the United States, 612 116 were younger than 65 years; 481 224 were 65 to 74 years of age; 599 206 were 75 to 84 years of age; and 457 358 were 85 years and older; the ages of 562 were not stated [5].

Another recent study [6] compared the cost of care associated with death between those who died at 85 years of age and older and those who died between 65 and 74 years of age. In the last year of life, 55% of Medicare and Medicaid expenditures on behalf of the younger group (65 to 74 years of age) went for hospital care, whereas for those 85 years and older, only 26% of Medicare and Medicaid expenditures was used for hospital care. In the older group, nursing home and home health care accounted for 62% of expenditures. Total costs in the last year of life were only 1% higher per person in those 85 years and older compared with those 65 to 74 years of age.

Much of the concern about the high cost of dying stems from studies showing that a large proportion of Medicare funds—a little under 30%—are spent on the small percentage of beneficiaries who die—around 6% [6-8]. But consider the actual figures. Lubitz and Prihoda [7] found that only 6% of those who died had more than $15 000 in Medicare costs and only 3% had more than $20 000. Binstock [9] points out that this 3% accounted for only six-tenths of 1% of the country's total health care bill. In all age groups, moreover, a high proportion of expenditures are incurred by a small percentage of patients [10]. Age does not appear to be the determining factor.

High-Technology Care

Another common assumption—that terminally ill, elderly patients are high users of expensive technology—is not borne out by available data. It appears, on the contrary, that aggressive interventions go more frequently not to the very old or terminally ill but to people with good functional status and good prospects for improvement and recovery [4]. As functional status declines among people 80 years and older, total expenses increase, but this is primarily due to greater use of nursing home and home health care, not to high-technology intensive care.

Moreover, when older people do receive high-technology care, their age has little to do with the prognosis. In fact, most older people who receive high-cost hospital care survive for an extended period [11]. Even among critically ill elderly patients requiring intensive care, severity of illness is a better predictor of survival than is age. In a study that compared the young old (65 to 74 years) with older persons (75 years and older), age made no difference in hospital charges, length of stay in the hospital, or mortality at 1 year. In both age groups, most patients rated their quality of life as adequate and said they would be willing to receive intensive care again, if necessary [12].

National Spending

Another misconception comes into play when the health care debate is cast in terms of equity between generations. According to one frequently heard argument, an unfair proportion of federal funds—30%—goes to entitlement programs for the older generation.

The issue is not so simple, however. Federal funds are only one segment of public monies. If we look at state and local funding, the picture could be quite different. For example, Arkansas spends about 11% of state funds on its two major budget items for elderly persons (the division for aging services and state Medicaid payments to those 65 years and older), Wisconsin spends about 3.5% on similar budget items, New York State about 8.3%, and Massachusetts about 4.8%. Overall, states and municipalities spend about 10 times more on education than they do on elderly persons [13]. None of these statistics provides the full picture of national spending on different generations, but they do suggest that the picture needs to be delineated in more detail if we are to use intergenerational equity as a debating point in discussions of health care costs.

The empirical data, in summary, offer little support for the politics of blame. It appears that age alone is not a reliable predictor of medical care outcomes or expenditures, nor is health care at advanced ages usually characterized by recourse to futile and expensive technologies. Clearly, some common assumptions about health care costs and elderly persons should be consigned to the realm of myth.

Gene D. Cohen, MD, PhD