Various factors affect the availability of good end-of-life care. Even basic demographic issues can have a drastic effect on how and where people die. According to the Dartmouth Atlas of Health Care (1998), produced by researchers at Dartmouth Medical School and the American Hospital Association, people in some areas of the country tend to die mostly in hospitals, while in other areas they are more likely to die at home. In some regions, half of all Medicare beneficiaries who died were in hospitals, while in other regions that rate was only 20 percent.
What makes this statistic so important? In a local health care system that has a relative oversupply of hospital beds, there will not be much of a system - or incentive - to get doctors to visit nursing homes or private residences; the community will expect that people die in the hospital. On the other hand, circumstances will force a system in which there are few hospital beds to develop more efficient home care, more ways to support very sick patients and their families at home, and strategies that often lower health care costs - while risking underservice at home.
Further, neither managed care nor fee-for-service structures include appropriate financial incentives to parallel the services that most people facing the end of life need. The Institute of Medicine report describes the problems people with chronic or progressive illnesses face in managed care. For instance, the composition of provider networks and other practitioners reflects the needs of the entire enrolled population and is not likely to reflect the diverse health care needs of people with chronic illnesses. Current capitated payment systems encourage enrolling low-risk people - plans do not want to enroll high-cost, chronically ill people. Fee-for-service plans are not a real match for this patient population, either, given the variety of needs - and the need for comprehensive, coordinated care - over extended periods.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].