Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA.
Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.
J Am Geriatr Soc. 2021 Apr;69(4):916-923. doi: 10.1111/jgs.16941. Epub 2020 Dec 24.
BACKGROUND/OBJECTIVES: To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA).
A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equations to evaluate monthly cost trajectories experienced by patients in their last year of life, with patients nested within hospital referral region.
Care received at VA facilities or by Medicare-reimbursed providers nationwide.
A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare.
We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12 months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life.
All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care.
Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.
背景/目的：评估通过医疗保险和退伍军人健康管理局（VA）治疗的癌症患者在生命末期的成本轨迹差异。
对 2010 年至 2014 年 VA 和医疗保险行政数据进行回顾性分析。我们采用三级广义估计方程来评估患者生命最后一年每月的成本轨迹，患者按医院转诊区域嵌套。
在 VA 设施或全国范围内由医疗保险报销的提供者接受治疗。
共有 36401 名死于癌症且同时参加 VA 和医疗保险的患者。
我们使用生命的最后 12 个月评估了总费用、住院费用、门诊费用和药物费用的轨迹。由于医疗保险和 VA 之间的成本不可直接比较，因此优先考虑成本轨迹。根据患者在生命的最后一年的医疗保健利用情况，将患者分为 VA 依赖型、医疗保险依赖型或混合依赖型。
所有三组患者在生命的最后一年中总费用的成本轨迹均存在显著差异。医疗保险依赖型和 VA 依赖型患者的住院费用轨迹明显不同，但 VA 依赖型和混合依赖型患者之间的住院费用轨迹没有差异。门诊和药物费用轨迹则呈现相反的模式：VA 依赖型和混合依赖型患者之间的费用轨迹明显不同，但 VA 依赖型和医疗保险依赖型患者之间的费用轨迹没有差异。然而，从视觉上检查成本轨迹可以发现，所有三组患者在生命的最后一年中都呈现出相似的成本模式；随着患者接近死亡，成本急剧上升，这主要是由于住院治疗。
尽管 VA 和医疗保险的财务激励机制和组织方式有很大不同，但接受 VA 和医疗保险治疗的患者在生命末期的成本增加模式相似，主要是由于住院费用。两个系统都需要改进，以确保临终关怀的质量与推荐实践相一致。
