Joanne Lynn, M.D.
RAND Center to Improve Care of the Dying
Ann O’Mara, R.N., Ph.D.
Living with, and eventually dying from, a chronic illness ordinarily runs up substantial costs for the patient, family, and society. Patients are sick, dependent, changing, and needy. Indeed, more than two dollars of every eight spent in Medicare is spent in the last year of life, and one in every eight is spent in the last month (Lubitz and Riley, 1993). Those with cancer have approximately 20 percent higher than average costs (Hogan et al., 2000).
High costs probably would be acceptable to all if patients and families were satisfied with the care provided for those with advanced disease, but few can count on being satisfied. Reports of inadequate symptom relief, uncertain responsibility for patient care across multiple care providers, family disruption and financial distress, inadequate planning ahead for serious disability and death, and other shortcomings are commonplace (IOM, 1997). In short, our society is spending a great deal and not getting what dying cancer patients need.
Many factors contribute to these shortcomings: inadequate attention to the problems, untrained professionals, absent quality standards, and so on. This chapter addresses the contribution to the shortcomings made by the financial arrangements covering care for people with advanced cancer. Changes in financing and coverage will not, on their own, change the standards of care (Vladeck, 1999), but changes in financing and coverage are an essential part of sustainable, comprehensive reform. Engineering a