The answer to reducing healthcare costs is to promote healthy ageing so as to reduce expensive periods of sickness before death, argues Mario Garrett.
As populations get older, healthcare costs increase. In 2010, Gerald Riley and James Lubitz reported that in the US the social health programme for older people, Medicare, spends around a quarter of its budget on people who will die that year. Since Medicare’s 2018 budget was $579 billion, a quarter of that is $145bn, which is 11 times the value of Malta’s goods and services in 2017 (GDP was $13 bn). Such dramatic statistics are often cited to attack the cost of healthcare for older people.
But this statistic is deeply flawed because we are very bad at predicting when older people are going to die. Only once patients die can we then go back and say “aha, all that medical care was useless”. But then we can say that for all patients who die. So the issue is predicting death in healthcare settings.
Despite all of our medical experience, it remains difficult to judge when people are going to die. For those working in hospice they understand this variability. Even though they are dying, some people hold on for a long time while others expire quickly. Some diseases have a clearer path towards death (e.g. some cancers), while others remain elusive (e.g. heart disease).
An Australian study in 2003 headed by Paul Glare and his colleagues found that doctors predicted death correctly within one week in a quarter of cases, and overestimated survival by at least a month for a quarter of their patients. The longer the patient is expected to survive the more likely the prediction is wrong. And this costs not only money but also gives the patient a false sense of timing. If we can predict more accurately this might not only lower apprehension for the patient but also lower costs.
Live long and healthy for as long as possible until we are ready to exit
A recent 2018 study by Liran Einav and his colleagues demonstrated that if we identify only individuals who are likely to die we find that Medicare spends less than five per cent on their care. But again this is flawed as those who do survive might die in two or three years’ time. The lesson that we take home from all these analyses is the difficulty in gauging the cost of care to older adults who are about to die.
What we do know is that older age populations, dying or not, use healthcare services more often. And that at the final stages before death this healthcare becomes increasingly costly.
The solution would seem to try and reduce the period older people need medical care before death.
As we get older, the period of a terminal illness shrinks. We live longer but we are frailer so when we get sick we are more likely to die quicker. Scientists call this observation the compression of morbidity. The older we get, the shorter the period (compression) of illness (morbidity) before we die.
The solution, therefore, is to promote the quality of our ageing so that our period of sickness before death is reduced. The idea is not to die earlier – we should promote growing older – but that we should just die quicker once we reach the end. However counter-intuitive and illogical this seems, the answer to reducing healthcare costs is to promote healthy ageing to reduce those expensive periods of sickness before death.
To test this we need to look at much older people. Centenarians are people who have reached 100 years of age. The United States’ large population contributes to it having the highest number of centenarians in the world, estimated at 72,197 in 2014. However, Japan, with 61,568 centenarians in 2015, has the highest percentage of centenarians. Out of 100,000 Japanese residents we expect to see 46 centenarians. You are twice as likely to become a centenarian in Japan than in the United States.
The interesting thing about centenarians is that although most of them live independently until age 92, by the time they reach the century mark, half are living in nursing homes, while only 15 per cent are still living alone. The rest are living with someone, or in assisted living facilities.
More importantly, centenarians tend to be healthy until they are not. Once centenarians get sick, they tend to have a sharp decline that usually leads to sudden death. This should be the ambition for most of us. Live long and healthy for as long as possible until we are ready to exit. No languishing in a hospital or nursing home.
However, this will not help healthcare costs since very few of us get to reach 100 years of age; especially in Malta where we have among the lowest rate of centenarians. The reality remains that most people start declining in health in middle age so that by the time they are in their 60s they have already started their slow decline.
We have seen very little improvement in this scenario, if at all. But it is heartening to know that theoretically the compression of morbidity predicts that we will reach a time where we will all reach our maximum age and then die rapidly without much medical intervention. Who would have known that this is the best scenario in life?
Mario Garrett was born in Malta and is currently a professor of gerontology at San Diego State University in California, US.