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WPVII - health care costs prior to death

WPVII - health care costs prior to death. Final conference AHEAD Brussels, 29 June 2007. S. Gabriele, M. Raitano and F. Tediosi Istituto di Studi e Analisi Economica, ISAE Roma. WPVII - health care costs prior to death Outline. Rationale of the WPs Main results of the literature review

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WPVII - health care costs prior to death

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  1. WPVII - health care costs prior to death Final conference AHEAD Brussels, 29 June 2007 S. Gabriele, M. Raitano and F. Tediosi Istituto di Studi e Analisi Economica, ISAE Roma

  2. WPVII - health care costs prior to deathOutline • Rationale of the WPs • Main results of the literature review • Health care costs/expenditure prior to death in Italy: • Objectives and methodology • Results • Relevance of results for policy making

  3. 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

  4. 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

  5. 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 Rationale

  6. 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) WPVII Literature review on health care costs prior to death worldwide

  7. WPVII Literature review on health care costs prior to death worldwide 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

  8. WPVII Literature review on health care costs prior to death worldwide 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

  9. WPVII Literature review on health care costs prior to death worldwide 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

  10. WPVII Literature review on health care costs prior to death worldwide 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

  11. 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

  12. WPVII Health costs prior to death in Italy Methods a) Assemble a database of health care consumptions at patient level Record linkage - through fiscal number and RECLUST approach Administrative databases of health care consumptions Death abstracts database Database of health care consumptions with data at individual level

  13. WPVII Health costs prior to death in Italy Methods b) Compute health care expenditure by age and gender • Expenditure estimated using national tariffs c)Compute health care consumption/expenditure prior to death – i.e. last 12 months – by age and gender

  14. WPVII Health costs prior to death in Italy Methods - data • 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

  15. WPVII Health costs prior to death in Italy 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

  16. WPVII Health costs prior to death in Italy Methods Main focus on hospital sector (43-49% of health care budget) • 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

  17. WPVII Health costs prior to death in Italy Methods • 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)

  18. WPVII Health costs prior to death in Italy 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

  19. WPVII Health costs prior to death in Italy Methods To compute health care expenditure in the last year prior to death, the subjects were distinguished in “cases” – deceased – and “controls” • “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

  20. WPVII Health costs prior to death in Italy 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

  21. WPVII Health costs prior to death in Italy Results: Hospital expenditure by age and gender of survivors Average expenditure: € 406 - €569 Men Women 2'200 1'800 2'000 1'600 1'800 1'400 1'600 1'200 1'400 Expenditure per capita € 1'200 1'000 1'000 800 800 600 600 400 400 200 200 0 0 1-4 1-4 90+ 90+ 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 20-24 50-54 70-74 30-34 60-64 10-14 40-44 80-84 Age Abruzzo Puglia Lombardia Toscana

  22. WPVII Health costs prior to death in Italy Results: Hospital expenditure by age and gender of deceased Average expenditure: €5,481- €5,868 Men Women 25'000 25'000 20'000 20'000 15'000 15'000 Expenditure per capita € 10'000 10'000 5'000 5'000 0 0 1-4 90+ 10-14 60-64 20-24 40-44 70-74 80-84 30-34 50-54 1-4 90+ 20-24 50-54 70-74 10-14 30-34 40-44 60-64 80-84 Age Abruzzo Puglia Lombardia Toscana

  23. WPVII Health costs prior to death in Italy Results: Hospital expenditure by age and gender of survivors and deceased 25.000 Deceased - men 20.000 Survivors - men Deceased - women 15.000 Survivors women Expenditure per capita € 10.000 5.000 0 1-4 90+ 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Age

  24. WPVII Health costs prior to death in Italy Results: Hospital expenditure by age and gender of survivors and deceased Men Women 2'600 1'800 2'400 1'600 2'200 1'400 2'000 1'800 1'200 1'600 Expenditure per capita € 1'000 1'400 1'200 800 1'000 600 800 600 400 400 200 200 0 0 1-4 90+ 1-4 90+ 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Age Abruzzo Puglia Lombardia Toscana

  25. WPVII Health costs prior to death in Italy Results: Hospital expenditure of deceased and survivors - ratio (deceased/survivors) Ratios all ages: 10.2 – 14.0 Men Women 120 250 100 200 80 Puglia 150 Abruzzo Ratio 60 Toscana Lombardia 100 40 50 20 0 0 90 + 1_4 90 + 1_4 20_24 30_34 40_44 50_54 60_64 70_74 80_84 20_24 30_34 40_44 50_54 60_64 70_74 80_84 10_14 10_14 Age

  26. WPVII Health costs prior to death in Italy Results: Hospital expenditure of deceased and survivors - ratio (deceased/survivors) Men Women 50 60 45 50 40 35 40 Puglia 30 Abruzzo 30 Ratio 25 Toscana Lombardia 20 20 15 10 10 5 0 0 90 + 40_44 45_49 50_54 55_59 60_64 65_69 70_74 75_79 80_84 85_89 90 + 40_44 45_49 50_54 55_59 60_64 65_69 70_74 75_79 80_84 85_89 Age

  27. WPVII Health costs prior to death in Italy Results: Hospital expenditure of deceased in the last 12 months – by proximity to death - Lombardia Women Men 4.000 4.000 3.500 3.500 3.000 3.000 2.500 2.500 Expenditure per capita - € Expenditure per capita - € 2.000 2.000 1.500 1.500 1.000 1.000 500 500 0 0 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 Months to death Months to death All Age 65+ Age 1-44 All Age 65+ Age 1-44

  28. WPVII Health costs prior to death in Italy Results: Hospital expenditure of deceased in the last 12 months – by proximity to death - Toscana Women Men 4.000 4.000 3.500 3.500 3.000 3.000 2.500 2.500 Expenditure per capita - € 2.000 2.000 Expenditure per capita - € 1.500 1.500 1.000 1.000 500 500 0 0 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 Months to death Months to death All Age 65+ Age 1-44 All Age 65+ Age 1-44

  29. WPVII Health costs prior to death in Italy Results: Hospital expenditure of deceased in the last 12 months – by proximity to death - Puglia Women Men 4.000 4.000 3.500 3.500 3.000 3.000 2.500 2.500 Expenditure per capita - € Expenditure per capita - € 2.000 2.000 1.500 1.500 1.000 1.000 500 500 0 0 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 Months to death Months to death All Age 65+ Age 1-44 All Age 65+ Age 1-44

  30. WPVII Health costs prior to death in Italy Results: Hospital expenditure of deceased in the last 12 months – by proximity to death - Abruzzo Men Women 4.000 4.000 3.500 3.500 3.000 3.000 2.500 2.500 Expenditure per capita - € 2.000 Expenditure per capita - € 2.000 1.500 1.500 1.000 1.000 500 500 0 0 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 Months to death Months to death All Age 65+ Age 1-44 All Age 65+ Age 1-44

  31. WPVII Health costs prior to death in Italy Results: Expenditure for outpatient specialist care, laboratory tests, and prescription drugs by age – deceased - Toscana 700 600 Outpatient specialist care 500 Laboratory tests 400 Expenditure per capita - € Prescription drugs 300 200 100 0 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Age

  32. WPVII Health costs prior to death in Italy Results: Expenditure for outpatient specialist care, laboratory tests, and prescription drugs by age – deceased in last 12 months 35 30 Outpatient specialist care 25 Laboratory tests Expenditure per capita - € 20 Prescription drugs 15 10 5 0 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 Months to death

  33. WPVII Health costs prior to death in Italy Relevance of results for policy making • 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

  34. WPVII Health costs prior to death in Italy 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

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