A DETAILED PROFILE OF THE END-OF-LIFE CARE IN MEDICARE

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The objectives of this proposed study are: 1. To document in detail the cost and patterns of end-of-life care for Medicare beneficiaries within five broad categories (cancers, dementia, congestive heart failure, chronic obstructive pulmonary disease, all other deaths). 2. To examine the geographic variations in cost and patterns of care within these categories, and determine the factors associated with variation in cost and patterns of care for these diseases. 3. To demonstrate methods for prospectively identifying cohorts of beneficiaries likely to be nearing end of life, and to calculate prospective capitation rates for these cohorts. The overall goal of this work is to obtain basic research needed to reshape Medicare payment policy for end-of-life care. Medicare's fractured fee-for-service payment discourages integrated management of end stage disease and encourages acute over palliative treatment. Integrated payment approaches (per diem, capitation, or other) have greater potential to encourage delivery of appropriate and compassionate end-of-life care. Restructuring Medicare policy toward more integrated payment requires identifying individuals likely to benefit from special end-of-life care, determining services and providers to be covered under an integrated payment, calculating Medicare's average cost for those services, and analyzing variation around that average cost. The proposed research will provide detailed data needed to discuss options for restructuring Medicare payment for end-of-life care. We propose a combination of descriptive analysis and hypothesis testing. First, because so little detailed information is available, we propose to create a databook on Medicare end-of- life care, a comprehensive profile of cost and use. Descriptive analyses will be guided by a National Advisory Board of experts in end-of-life care, with a goal of developing a useful reference on Medicare-financed end-of-life care. Second, we will test specific hypotheses regarding cost and use.