I'm new to this discussion, so I'm not sure if this point has been made yet, but I don't hear many folks these days when discussing the cost of health care raise the question about the ROOT CAUSE of the mess it all is. In my mind, focusing on the health system is looking at symptoms or consequences, not sources or causes. Imagine the impact on health care if people received better education about their own bodies, felt empowered by that knowledge, and took more of their own responsibility to be healthy. So many people are of the mindset "full steam ahead, damn the torpedoes!" when it comes to their lifestyles, figuring "the doctor will fix it" when they get sick or injured. It is a classic case of co-dependency in our society, where the sick need the health professionals, and the health professionals NEED the sick (an unhealthy society is, after all, great job security!)

How do we wake up the sleeping "beast" that is the vast majority of Americans who won't do preventively for themselves what no advertisement campaign in the world will "fix?" Sure, we can see some progress over the years, most notably, the decrease in tobacco dependency. Maybe we're even exercising more. But the increase in childhood obesity and diabetes alone should scare the hell out of all of us. There are no quick fixes for those conditions. To me, they're the "canaries" in the dark cave of health care. Kids depend on us for education, and they obviously aren't getting it. And we aren't giving it.

The cynical side of me says a lot of corporations stand to benefit from keeping the masses in the dark about their bodies and good health. Does anyone LIKE the proliferation of drug commercials on TV? And what do so many of them suggest: "talk to your doctor about Drug X." We're going to experience a great deal of pain and financial drain before the cart gets put in back of the horse where it should be. I'd like to hear just one Presidential candidate suggest this approach instead of all the other crap I've heard so far. Anyone else with me on this?

Expand full comment

God can giveth the cancer, and he can taketh it away. G, don't you believe in miracles? :)

Expand full comment

Are you using "medicine" in a startlingly narrow way, or have I spectacularly misunderstood you, or did you really just say that you doubt that treating cancer saves any lives?

Expand full comment

Anyone got any figures for what fraction of medical expenditure is on treatment of people *who would have been within N years of death even without the particular problem the expenditure was trying to deal with*?

Such figures would involve knowing if medicine actually works. It may be possible to figure out how much money is spent on 30 year-olds with cancer and break it into the groups who survived & those who didn't, but I doubt that the cancer medicine saved anyone.

Expand full comment

I answered that last question before you asked it (2007-09-23, 18:23).

As for arguing about something that's probably true: (1) what I'm "arguing" about is whether BillK's figures were just made up or not, which seems to me to be of some interest whether or not they're roughly right, (2) I gave some reasons for being suspicious about any argument founded merely on the fraction of expenditure in the last year / N years of life, (3) even when there's general agreement that something is probably true there's scope for discussion about how probably it's true and how strongly it should be stated for best accuracy, and (4) sometimes something can be very widely believed but still false.

In this instance, it seems that there's plenty of folklore to the effect that US healthcare costs for people close to death are very high, and that this indicates that a lot of resources are going into extending lives that aren't going to last long (or: whose quality isn't very high regardless) anyway. But it's still not very clear whether there's much more than folklore. The fact that the authors of that RAND report from 2003 chose to draw that astonishingly unquantitative Figure 1 suggests to me that there aren't any good figures to be had. (Or that there are, but that they don't look as convincing as the impressionistic Figure 1.) I hope I'm wrong, since these seem like vital facts that need to be taken into account in framing healthcare policy.

Expand full comment

Why are we arguing about something that is probably true? Does anyone here actually not think that a significant portion of healthcare costs accrue during the last few years of life?

What about you, g?

Expand full comment

So I take it that the original 70% and 35% figures were in fact pulled out of the air (though apparently not by you but by the doctor you now mention) as representatives of the less precise but more accurate statement that "The overwhelming preponderance of US health care costs now arise in the final years of life". As I said, I don't think you should do that.

For the benefit of anyone who hasn't taken a moment to look at figure 1 of that white paper, I'll mention that its x-axis has exactly three labels ("Birth", "Life span", "Death"), its y-axis exactly one ("Expenditure"), and that it seems obvious that the curve it shows was drawn freehand and not directly derived from any actual data.

Expand full comment

The doctor who quoted the original percentages has got back to me.He works as an Emergency Room director in a large hospital.

He says that there is no point in referencing studies and reports as they all have different numbers and you can get support for almost any figure you fancy.

He says that his 70%/5 years and 35%/1year spending estimate is a very conservative consensus view. In some cases over 90% is spent in the last year of life.

So I would stick with the 2003 RAND reporthttp://www.medicaring.org/w...

That saysThe overwhelming preponderance of U.S. health care costs now arise in the final years of life. Indeed, if one were to estimate costs across a life span, the shape of the expenditures reflects the new health and demographic circumstances. Figure 1 presents a rough estimate of health care costs distributed across the average American's lifetime.

The graph shown in Fig.1 on page 1 of this whitepaper certainly agrees.


Expand full comment

But that isn't at all what you said. "70% of medical spending goes on the last five years of life" and "70% of medical spending goes on heart disease, cancer and diabetes" have *nothing* to do with one another beyond both mentioning "70% of medical spending".

I'm sure you're right that (1) a lot of US medical spending is on people near the ends of their lives, (2) quite a lot of it is on people *very* near the ends of their lives, and (3) it might be effective, in terms of getting more QALYs-per-buck, to reduce that. But (and I'm sorry to be repeating myself here) you quoted a couple of quite specific figures, and there doesn't yet seem to be any evidence that you weren't just making those figures up. And I don't think you should do that.

One other thing. Suppose you get cancer at 30 and die three years later. Then any medical treatment you got during that time will have been "in the last 5 years of life". It seems to me that this discussion has been framed so as to make end-of-life treatment sound as if it's all aimed at enabling people to live to 93 instead of 92. Unless we know what fraction of this end-of-life treatment was actually aimed at enabling people to live past 33 instead of dying then but happened not to succeed, I think a discussion on those terms is inviting all sorts of broken intuitions.

Anyone got any figures for what fraction of medical expenditure is on treatment of people *who would have been within N years of death even without the particular problem the expenditure was trying to deal with*?

Expand full comment

I think I've found that 70% quote.


The Burden of Chronic Diseases and Their Risk Factors:National and State Perspectives 2004

Preface:Chronic diseases such as heart disease, cancer, and diabetes are leading causes of disability and death in the United States. Every year, chronic diseases claim the lives of more than 1.7 million Americans. These diseases are responsible for 7 of every 10 deaths in the United States. Chronic diseases cause major limitations in daily living for more than 1 of every 10 Americans, or 25 million people. These diseases account for more than 70% of the $1 trillion spent on health care each year in the United States.

Expand full comment

Sorry. At the moment I am unable to find a 'fact-sheet' or even a RAND study that quotes the exact percentages I mentioned. But arguing about the exact percentage is avoiding the point that, for example, over half of medical expenditure is spent in the final years of life, when it will make little difference to the health benefits statistics.

You're the health statistician - what do you think the percentages are?

There are two scenarios at work here, which confuses the statistics.

Firstly, the general point, which I don't think anyone disputes, is that medical costs for the elderly (over 65s) is much higher than for younger ages.

http://findarticles.com/p/a...The lifetime distribution of health care costsHealth Services Research, June, 2004 by Berhanu Alemayehu, Kenneth E. Warner

The distribution of health care costs is strongly age dependent, a phenomenon that takes on increasing relevance as the baby boom generation ages. After the first year of life, health care costs are lowest for children, rise slowly throughout adult life, and increase exponentially after age 50 (Meerding et al. 1998). Bradford and Max (1996) determined that annual costs for the elderly are approximately four to five times those of people in their early teens. Personal health expenditure also rises sharply with age within the Medicare population. The oldest group (85+) consumes three times as much health care per person as those 65-74, and twice as much as those 75-84 (Fuchs 1998). Nursing home and short-stay hospital use also increases with age, especially for older adults (Liang et al. 1996).----------About half of all health care expenses in a person's lifetime occur after age 65Alemayehu, B. and K.E. Warner (June 2004). "The Lifetime Distribution of Health Care Costs." Health Services Research, 39(3), 627-642.-----------

The high proportion of medical costs invested in the elderly produce relatively small gains in extended lifespan.

Secondly, when younger people become seriously ill, then typically very aggressive and expensive treatments will be used to try to save their life. Although, in total, these sick younger people are fewer in number than the elderly, if they die, then their medical costs should be added to the 'final years of life' total medical costs.

If you add, say ~20%, for younger deaths, to the ~50% for older deaths, then you are around the 70% figure I quoted for 'end-of life' medical costs.

I must say though, that I find all these medical statistics reports rather confusing. But I think the overall conclusion still holds - that high 'end-of-life' medical costs is the main factor in making the US health stats look bad.

Expand full comment

Robin,What about all the people who die each year but were not old enough for Medicare benefits?

Expand full comment

g,the 61% that BillK quotes seems to answer your question. But it bumps the 5% up to 8%.

Expand full comment

BillK, you originally gave some quite specific figures: 70% and 35%. Where did those particular figures come from? I agree that if the correct figures turned out to be 50% and 20%, or 80% and 30%, or whatever, then it wouldn't make a big difference, but I'm still curious where you got your numbers from.

Robin, is there reason to think that medical treatment in the last year of life is all, or almost all, done by Medicare? (That's a genuine question; I'm very ignorant.) If not, then the fact that the most conservative lower bound available from BillK's citation is 5% isn't quite to the point.

Expand full comment

Robin, thoughts about these numbers beyond correcting the details of foil BillK?

Expand full comment

Bill, this fact sheet says Medicare benefits are 20% of total U.S. medical spending. So one-quarter of Medicare benefits is 5% of total spending, much less than your 30% figure.

Expand full comment