While pet insurance can reduce the cost of vet visits, its primary usage is in medical emergencies.
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The closer you are to an urban area such as New York, Toronto or places like Kentucky or Florida that are horse meccas, the more expensive horse ownership can become. You will also pay for extras such as farrier and veterinary care, special feeds or care such as removing and putting on blankets and fly masks.
In self-care facilities, the monthly board is less expensive, but you will supply your own feed and bedding and travel to care for your horse daily. One thing that really can throw your budget is unexpected veterinarian bills. The cost for off-hour calls can be very expensive and something like colic surgery can cost thousands or tens of thousands, depending on what procedures you choose to do.
Or, your horse may need more than one-half bale. Feeding more expensive concentrates or supplements. A horse that is ill or injured. Because hospital expenditures account for such a large part of total medical care expenditures 42 percent in , questions arise regarding the use of hospital services.
Has the use of the hospital as a place to die increased in recent years? In short, do the available data support the hypothesis that we are spending too much of our medical dollar on the dying and, therefore, suggest that one way of curbing rising medical care costs is to target cost-containment efforts on this group? This is the basic question which will be explored in this article.
Studies of medical care expenditures at the end of life can be classified into two broad groups: 1 studies dealing specifically with expenditures of those who die, and 2 studies of high-cost or catastrophic illness in general which also provide some information on the share of these costs incurred by patients who do not survive. One of the earliest in the first group is a study of hospital use in the last year of life Sutton It showed that 48 percent of all deaths occurred in short-stay hospitals, and that 63 percent of all decedents used some hospital services in their last year of life; corresponding figures for decedents aged 65 years and over are 45 percent and 61 percent, respectively.
This study does not have data on costs, nor on the use of hospital services by patients who did not die. Such data are provided by a somewhat later study, by Timmer and Kovar , of expenses for hospital and institutional care during the last year of life of adults aged 25 and over who died in and In yet another study, Selma Mushkin estimated that in over 20 percent of all nonpsychiatric hospital and nursing home expenditures in nongovernment facilities were for the care of patients who died.
Several studies have examined the costs of care of cancer patients who died. More recently, a study of cancer costs in the last six months of life has been conducted by the Blue Cross and Blue Shield Association under contract with the Department of Health and Human Services. Since the enactment of Medicare in , several studies have examined Medicare reimbursements on behalf of beneficiaries who died.
The earliest of these studies, by Piro and Lutins , of Medicare beneficiaries who died in or showed that the 5 percent of Medicare beneficiaries who died in accounted for 22 percent of all Medicare reimbursements in that year. Finally, a considerably more detailed study, conducted at HCFA by Lubitz and Prihoda , has recently been published.
They found that the 5. It should be noted that in contrast to the study by Piro and Lutins and the study by Helbing, which included only Medicare reimbursements made for costs incurred in the calendar year in which the enrollee died i. These are the principal studies dealing specifically with medical care costs of persons who died.
In addition, there have been several studies of high-cost or catastrophic illness which show that a considerable portion of these costs is incurred by patients who die. For example, a study by Schroeder, Showstack, and Roberts , which analyzed the experience of high-cost patients treated in a sample of San Francisco Bay Area hospitals in , showed that 15 percent died while in the hospital.
A follow-up study indicated that two years after discharge, at least 34 percent of the patients had died Schroeder, Showstack, and Schwartz Several studies of costs incurred in hospital special or intensive-care units also indicate a high use of resources by patients who do not survive hospitalization. Turnbull et al. Cullen et al. Thibault et al. What do these studies tell us about the costs of medical care at the end of life?
The various studies of hospital use by decedents compared to survivors all show significantly higher levels of use and expenditures by the former than the latter. However, they are limited to hospital costs and hence do not give a full picture of total costs of care. The same is true of the studies of high-cost or catastrophic illness.
In addition, most of these studies are based on treatment practices in teaching hospitals, and it is doubtful to what extent these practices are found in community hospitals which do not have all the high-technology facilities of tertiary-care centers.
Moreover, even the authors themselves generally hesitate to call the aggressive treatment they document inappropriate or wasteful but only suggest that it needs further study. Thus, these studies do not provide a basis for evaluating how much aggressive care of clearly terminal patients goes on in the country as a whole, much less how much this is costing the country. The studies of the costs of treating patients who died of cancer are somewhat more informative.
In contrast to the studies of high-cost illness, which generally deal only with hospital costs, the cancer studies provide data on practically all costs. However, they are limited to one specific disease and hence again provide only partial information, although Lubitz and Prihoda , found that the pattern of expenses in the last year of life of patients who died of cancer was virtually identical to that of all decedents.
This leaves the Medicare studies, which are the best source of information on costs at the end of life available to date, although they too have their limitations. For one thing, they provide data only for persons aged 65 years and over who are covered by Medicare.
However, since this age group accounts for 67 percent of all deaths, and since most persons in this age group are covered by Medicare, these studies do provide information for a large part of the population. A more serious shortcoming is the fact that the studies furnish data only for services covered by Medicare.
The major omissions are expenses for nursing home care, which Medicare covers only to a very limited extent, and for outpatient drugs, which it does not cover at all. The omission of nursing home costs is especially serious. The omission of drug expenses, though less important, is also not negligible. Moreover, even for services covered by Medicare—hospital services covered by part A and physician services covered by part B —the Medicare studies do not provide data on total expenses but only on Medicare reimbursements.
Because of differences in deductibles and cost-sharing provisions under the two programs, Medicare disbursement data understate total expenses for physician services to a greater extent than expenses for hospital services. In , for example, Medicare paid for These limitations must be kept in mind when evaluating the Medicare data on costs incurred by persons who died compared to those incurred by survivors.
It is difficult to estimate which way the omission of nursing home and drug expenses and the understatement of total hospital and physician expenses because of deductibles and cost-sharing provisions bias the findings. On balance, these factors may make for a greater understatement of total expenses by survivors rather than decedents. But we really do not have adequate data, especially on nursing home expenses, to arrive at a definite conclusion at this time.
Of the four Medicare studies cited, the one by Lubitz and Prihoda is the most detailed and will, therefore, be summarized here. Moreover, while the absolute figures in the four studies differ, all show the same general trends and relationships between Medicare expenses of decedents compared to those of survivors.
These mirror the findings for the last year, but the total figures and differences between the two groups are smaller. In addition to their finding that the 5. However, these figures would probably change considerably if nursing home expenses were included, which increase with increasing age. Total expenditures of both groups would be higher; expenses of decedents might not decrease with increasing age, but what would happen to the differential between the two groups is difficult to say for lack of adequate data.
Because hospital expenses account for such a large part of total Medicare reimbursements for persons in their last year of life, two questions posed at the beginning of this article are worth exploring briefly: 1 Has the use of the hospital as a place to die increased over the last decade or two, and 2 are the high costs at the end of life due largely to aggressive care, and has the relative intensity of hospital care of patients who die compared to those who survive increased?
Data on the number of deaths by place of death are surprisingly scarce. The main problem is one of definition since sometimes the data refer to short-stay hospitals only, sometimes to short-stay hospitals and long-term care institutions combined; moreover, to complicate matters still further, the definition of an institution is not always the same.
Because of the scarcity of data, all available data on hospital and institutional use in the last year of life have been assembled in Table 1. As can be seen from the many blanks in the table, data on the subject are indeed few.
Entry 1 of the table presents a summary of data on the percentage of deaths occurring in short-stay hospitals. This percentage stood at 48 percent in , was 45 percent and 44 percent, respectively, in and , and amounted to 50 percent in —not a dramatic rise over a year period. Entry 2 shows the percentage of decedents who had some care in short-stay hospitals in the last year of life.
Here indeed we find an increase for decedents aged 65 and over no recent data are available for the total population from 61 percent in to 75 percent in However, the 61 percent figure for is not strictly comparable to the others because the data in this study refer to hospital use in the calendar year of death only, not in the 12 months preceding death. A rough estimate of the percentage of decedents with some use of short-stay hospitals in the full 12 months before death can be made on the basis of the finding by Lubitz and Prihoda that Medicare reimbursements in the last six months of life accounted for 77 percent of total Medicare reimbursements in the 12 months before death.
Adjusting the 61 percent figure for the missing months of utilization 61 divided by 77 times makes the figure for the full 12 months before death 79 percent. She found that 79 percent of all inpatient hospital days of aged beneficiaries who died occurred in the last six months before death. Adjusting the Piro and Lutins figure accordingly makes their figure for the full 12 months 77 percent. Thus, the increase in the use of hospital care in the last year of life did not occur recently but around the mid- to late s after the introduction of the Medicare and Medicaid programs.
For the sake of completeness, similar data for hospitals and institutions combined are shown in entries 3 and 4 of the table. Again, these data do not suggest significant changes in recent years. It is of interest to note that the study from which the data for , , and in entry 3 are taken also cites data for , the earliest year for which this kind of information is available.
At that time, 37 percent of all deaths occurred in hospitals and institutions. Thus, it appears that the big shift to dying in hospitals and institutions occurred before or right after World War II rather than in more recent times. To sum up, the available data do not show a dramatic rise in the last 20 years in the use of the hospital as a place to die. They do show, however, that hospital use in the last year of life has increased substantially over the last 20 years, especially between the early and late s rather than more recently.
Data on the second question, regarding the intensity of hospital care of patients who die, are also scarce, although it is often assumed that the high medical-care costs at the end of life are due largely to aggressive and intensive treatment. She found that 67 percent of all inpatient charges incurred by decedents in their last year of life were incurred in the last quarter, while only 61 percent of their inpatient days in the last year occurred in the last quarter.
Thus, her finding does not necessarily indicate especially intensive or aggressive care at the end of life. Both her study and the study by Lubitz and Prihoda found that only a relatively small number of decedents had very high medical expenses in the last year of life, the kind of expenses which would indicate the use of costly, high-technology hospital services.
In retrospect it is easy to regard these latter expenses as justified and to question the appropriateness of the expenditures for those who died. But it is likely that prospectively the distinction between those who would die and those who would live was not nearly so clearcut. A comparison of data from two other Medicare studies—the study by Piro and Lutins and the study by Helbing—can shed some light on the question whether the relative intensity of hospital care of patients who die compared to those who survive has increased.
The two studies used the same methodology in that the data on Medicare reimbursements for decedents include only payments made for services rendered in the calendar year of death, not in the entire month period preceding death as does the study by Lubitz and Prihoda. Thus, there has been only a minor change in the relative intensity of hospital care of decedents compared to survivors. Expressed in terms of expenditures per enrollee instead of per user of services, the data show much the same minor differences.
The ratios of hospital insurance reimbursements per decedent and per survivor are 5. The ratios for all services are equally close—4. This does not mean, of course, that there has been no increase in the intensity of hospital care over this period. But it appears that the increase in resources used in the hospital has been proportionately the same for patients who die and those who survive. To sum up, three principal conclusions can be drawn from the various studies of expenditures at the end of life:.
Medical care costs at the end of life are indeed high. Even expenditure data which exclude many expenses—such as the Medicare data which exclude the costs of nursing home care and outpatient drugs—show that medical care in the last year or months of life costs a great deal. The high cost of medical care at the end of life is not a recent development, something which only happened in the course of the last few years.
Data for show much the same relationship between expenditures for sick people who died and expenditures for those who survived. In fact, even before the advent of Medicare, a study showed that hospital and other institutional expenses of sick adults who died were almost three times those of sick adults who did not die. The reason why the data on costs at the end of life raise so much concern at present while they went virtually unnoticed 15 or 20 years ago is probably that we are much more concerned about the costs of medical care in general now that they account for over 10 percent of the gross national product than in the days when they were about 6 percent.
Finally, and most important, the data available at present—and they are admittedly meager—do not support the frequently voiced or at least implied assumption that the high medical expenses at the end of life are due largely to aggressive, intensive treatment of patients who are moribund.Закладка в тексте
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