WPVII - health care costs prior to death Final conference AHEAD Brussels, 29 June 2007 S. Gabriele,...

WPVII - health care costs prior to death

Final conference

AHEAD

Brussels, 29 June 2007

S. Gabriele, M. Raitano and F. TediosiIstituto di Studi e Analisi Economica, ISAE Roma

WPVII - health care costs prior to death Outline

1) Rationale of the WPs

2) Main results of the literature review

3) Health care costs/expenditure prior to death in Italy:

Objectives and methodology Results

4) Relevance of results for policy making

WPVII Rationale

Exploring the link between age and health care expenditure

It is usually stated that ageing will boost HCE

There is empirical evidence that the bulk of health care costs is concentrated in the last months of life

The correlation between age and HCE could be (at least in part) a spurious one, depending on the high correlation between age and death

The relationship between ageing and HCE is more complex than usually stated

WPVII Rationale

Exploring the link between age and health care expenditure

Increase in longevity will decrease the mortality rate in the “medium old” age group, postponing “death costs”

Declines in age specific mortality lead to declines in age specific costs because declining mortality reduces the proportion of high costs users (i.e. those near to death)

There are important consequences for health expenditure projections

WPVII Rationale

Are the risks for health systems sustainability due to ageing overstated?

Is it a way to claim for more resources that will increase the income of health care providers?

Ageing as a justification for past increases in spending, which can distract from the actual causes of growth and from considerations of appropriateness or effectiveness?

Dilemma between good management - and appropriateness - and sales/employment maximisation

The study of health costs prior to death can help policy making

WPVII Literature review on health care costs prior to death worldwide

3 types of studies:

“Descriptive” - evaluating the evolution of death costs per age of death, and the ratio, by age, between health care expenditures of decedents and survivors (N=18)

“Econometric” - estimating if age and distance from death are significant drivers of health care costs (N=7)

“Projection” studies - calculating the difference emerging between health care costs projections including or not the “death costs” assumption (N=13)

Descriptive studies

The bulk of health care costs is concentrated in the last years (or months) of life

The Decedent/Survivors health costs ratio is very high and decreases with age

wide consensus (shown by econometric analysis too) that in the health sector death costs decrease at higher age

e.g. Lubitz et al. show that Medicare costs in the last 2 years of life for a 70 yrs old decedent were over 50% higher than for a 90 yrs old decedent


Descriptive studies

But long term care costs increase in the last years of life in the oldest age group as well

This may be due to the different kind of care needed by the oldest old near to death

Then, the age-decreasing pattern of health care death costs may be partially offset by the age-increasing pattern of long term care death costs


Econometric studies Wide debate on econometric methods to be used to estimate the drivers of HCE…...but also consensus on the results

Proximity to death have significant effects on health care costs, while some studies show that age is not significant e.g.:

Zweifel et al. find that age isn’t a significant driver of health care costs; they conclude that the relationship between age and health care expenditure is a red herring

Seshamani & Gray show that age is significant, but it is not the main driver of HCE; the main driver is proximity to death …….age is, at least in part, a red herring in relation to health care expenditure


Projection studies

Age alone is not a good basis for predicting the effects of ageing….time to death method yields lower projections, but it doesn’t offset the impact of ageing

The projections strongly depend on the method chosen to include the death costs assumption

No wide consensus on how to include the death related costs assumption


WPVII Health costs prior to death in Italy

Objectives To estimate health care expenditure:

by “distance from birth” - i.e. age by distance from death - i.e. the cost of the

last months of life

To distinguish between “old age costs” and “death costs” for informing health care expenditure projections


Record linkage - through fiscal number and RECLUST approach

Methods

a) Assemble a database of health care consumptions at patient level

Administrative databases of health care consumptions

Death abstracts database

Database of health care consumptions with data at individual level

Expenditure estimated using national tariffs

Methods

b) Compute health care expenditure by age and gender

c) Compute health care consumption/expenditure prior to death – i.e. last 12 months – by age and gender


National versus regional

Decentralization of Italian NHS implies that differences among regional health systems, already relatively wide, are increasing

In different Regions of Italy now the health care model is relatively different

Methods - data


National versus regional

Lack of good quality data at national level - e.g. Detailed data on mortality available on request, but record

linkage with health care consumption databases is hard Health care consumption data at patient level not available

Better quality data at regional level: In a number of Regions data at patient level are available at

least for hospital sector

Methods - Data



4 Regions Lombardia (north - over 9 m. residents) Toscana (centre - 3.5 m. residents) Abruzzo (south 1.3 m, residents) Puglia (south – 4.1 m. residents)

All together these Regions account for around 34% of the Italian population

Methods

Main focus on hospital sector (43-49% of health care budget)

The Regional Health Systems of the 4 Regions are relatively different in terms of: Inputs Organisation Public private mix

The population structure is also different

Explorative analysis on outpatient specialist care, laboratory tests, and prescription drugs in one Region (Toscana)


Methods


Methods - data

Mortality: regional death abstracts databases, and a

national database provided by the national statistical institute (ISTAT, Mortalità per causa nelle regioni) - year 2000 and 2001

Hospital discharge abstracts: of year 1999, 2000, and 2001


“Cases”: subjects deceased in year 2000 deceased in 2000 and admitted in hospital in

2000 deceased in 2000 and admitted in hospital in

1999 within 12 months before dying deceased in 2000 and never admitted in

hospital in the last 12 months of life

To compute health care expenditure in the last year prior to death, the subjects were distinguished in “cases” – deceased – and “controls”

Methods


“Controls”: Subjects alive at 1.1.2001, and surviving at

least 12 months after the hospital admission: admitted in 2000 and in 1999 too - only admissions in

2000 are included admitted between 1999 and 2000 or 2000 and 2001 - are

considered only the days of stay in 2000 deceased in 2001 and admitted in 2000 only for the days

of stay precedent the 12 months from death

Subjects never admitted and alive at 1.1.2001 Hospital admissions in the last year of life of subjects

deceased in 2001 were excluded

Methods


Average expenditure: € 406 - €569

0200400600800

1'0001'2001'4001'6001'8002'0002'200

1-4

10-1

4

20-2

4

30-3

4

40-4

4

50-5

4

60-6

4

70-7

4

80-8

490

+

Age

Exp

end

itu

re p

er c

apit

a €

PugliaAbruzzo ToscanaLombardia

Results: Hospital expenditure by age and gender of survivors

0

200

400

600

800

1'000

1'200

1'400

1'600

1'800

1-4

10-1

4

20-2

4

30-3

4

40-4

4

50-5

4

60-6

4

70-7

4

80-8

490

+

Men Women

Average expenditure: €5,481- €5,868

0

5'000

10'000

15'000

20'000

25'000

1-4

10-1

4

20-2

4

30-3

4

40-4

4

50-5

4

60-6

4

70-7

4

80-8

490

+

Age

Exp

end

itu

re p

er c

apit

a €

0

5'000

10'000

15'000

20'000

25'000

1-4

10-1

4

20-2

4

30-3

4

40-4

4

50-5

4

60-6

4

70-7

4

80-8

490

+

Men Women


WPVII Health costs prior to death in ItalyResults: Hospital expenditure by age and gender of deceased


Results: Hospital expenditure by age and gender of survivors and deceased

0

5.000

10.000

15.000

20.000

25.000

1-4

10-1

4

20-2

4

30-3

4

40-4

4

50-5

4

60-6

4

70-7

4

80-8

490

+

Age

Ex

pe

nd

itu

re p

er

ca

pit

a €

Deceased - men

Deceased - women

Survivors - men

Survivors women


0200400600800

1'0001'2001'4001'6001'8002'0002'2002'4002'600

1-4

10-1

4

20-2

4

30-3

4

40-4

4

50-5

4

60-6

4

70-7

4

80-8

490

+

Age

Exp

end

itu

re p

er c

apit

a €

0

200

400

600

800

1'000

1'200

1'400

1'600

1'800

1-4

10-1

4

20-2

4

30-3

4

40-4

4

50-5

4

60-6

4

70-7

4

80-8

490

+


Men Women

Results: Hospital expenditure by age and gender of survivors and deceased


0

20

40

60

80

100

120

1_4

10_1

4

20_2

4

30_3

4

40_4

4

50_5

4

60_6

4

70_7

4

80_8

4

90 +

Age

Rat

io

0

50

100

150

200

250

1_4

10_1

4

20_2

4

30_3

4

40_4

4

50_5

4

60_6

4

70_7

4

80_8

4 90

+

PugliaAbruzzoToscanaLombardia

Men Women

Results: Hospital expenditure of deceased and survivors - ratio (deceased/survivors)

Ratios all ages: 10.2 – 14.0


Age

PugliaAbruzzoToscanaLombardia

Men Women

0

5

10

15

20

25

30

35

40

45

50

40_4

4

45_4

9

50_5

4

55_5

9

60_6

4

65_6

9

70_7

4

75_7

9

80_8

4

85_8

9

90 +

Rat

io

0

10

20

30

40

50

60

40_4

4

45_4

9

50_5

4

55_5

9

60_6

4

65_6

9

70_7

4

75_7

9

80_8

4

85_8

9

90 +

Results: Hospital expenditure of deceased and survivors - ratio (deceased/survivors)


Results: Hospital expenditure of deceased in the last 12 months – by proximity to death - Lombardia

Men

0

500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1

Months to death

Exp

end

itu

re p

er c

apit

a -

€

All Age 65+ Age 1-44

Women

0

500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1

Months to death

Exp

end

itu

re p

er c

apit

a -

€



Results: Hospital expenditure of deceased in the last 12 months – by proximity to death - Toscana

Men

0

500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1

Months to death

Exp

en

dit

ure

pe

r ca

pit

a -

€


Women

0

500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1

Months to death

Exp

en

dit

ure

pe

r ca

pit

a -

€



Results: Hospital expenditure of deceased in the last 12 months – by proximity to death - Puglia

Men

0

500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1

Months to death

Exp

end

itu

re p

er c

apit

a -

€


Women

0

500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1

Months to death

Exp

end

itu

re p

er c

apit

a -

€



Results: Hospital expenditure of deceased in the last 12 months – by proximity to death - Abruzzo

Men

0

500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1

Months to death

Exp

en

dit

ure

pe

r ca

pit

a -

€


Women

0

500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1

Months to death

Exp

en

dit

ure

pe

r ca

pit

a -

€



Results: Expenditure for outpatient specialist care, laboratory tests, and prescription drugs by age – deceased - Toscana

0

100

200

300

400

500

600

700

0-4

10-1

4

20-2

4

30-3

4

40-4

4

50-5

4

60-6

4

70-7

4

80-8

4

Age

Ex

pe

nd

itu

re p

er

ca

pit

a -

€

Outpatient specialist care

Laboratory tests

Prescription drugs


0

5

10

15

20

25

30

35

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1

Months to death

Ex

pe

nd

itu

re p

er

ca

pit

a -

€

Outpatient specialist care

Laboratory tests

Prescription drugs

Results: Expenditure for outpatient specialist care, laboratory tests, and prescription drugs by age – deceased in last 12 months


This WP confirms the results of other studies

(Italian) socio-economic and institutional regional differences do not seem to affect significantly the results No significant impact on health care costs prior to

death, expenditure by age, and ratio expenditure decedents/survivors

Relevance of results for policy making


From a macro economic perspective distinguishing “death costs” from “old age costs” can inform health expenditure projections

From a micro economic perspective distance from death is an important factor for explaining health expenditure concentration in specific population groups

Relevance of results for policy making

WPVII - health care costs prior to death Final conference AHEAD Brussels, 29 June 2007 S. Gabriele,...

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