Project

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Do high health care expenditures at end of life reflect preferences of the Swiss population?

English title Do high health care expenditures at end of life reflect preferences of the Swiss population?
Applicant Beck Konstantin
Number 145096
Funding scheme NRP 67 End of Life
Research institution CSS Versicherung
Institution of higher education University of Zurich - ZH
Main discipline Economics
Start/End 01.01.2013 - 30.04.2016
Approved amount 255'848.00
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All Disciplines (2)

Discipline
Economics
Medico-Social Problems of the Elderly

Keywords (7)

Health economics; Health care expenditures; Social health insurance; Demography; End of life costs; Willingness to pay; Ageing

Lay Summary (German)

Lead
Was kosten lebensverlängernde Massnahmen bei Sterbenden und wie viel ist unsere Gesellschaft bereit, dafür auszugeben? Mit einem Experiment zur Zahlungsbereitschaft der Schweizer Bevölkerung für medizinische Behandlungen am Lebensende sollen in diesem Projekt diese und weitere Fragen beantwortet werden.
Lay summary

Hintergrund
Wie viele medizinische Behandlungen vor dem Tod gibt es mit geringem Nutzen? Welchen Preis dürfen lebensverlängernde Massnahmen haben? Und was denkt die Schweizer Bevölkerung über Kosten und Wert von lebensverlängernden Massnahmen? Dies sind schwierige Fragen, denen sich die Gesellschaft stellen muss. Denn bis zu 1/4 aller Gesundheitsausgaben werden kurz vor dem Tod verursacht und es ist zu erwarten, dass medizinischer Fortschritt und intensivere Behandlungen die Kosten in der letzten Lebensphase weiter ansteigen lassen. Aufgrund der alternden Bevölkerung wird befürchtet, dass die Gesundheitsausgaben eines Tages nicht mehr tragbar sind und dies zu Rationierungen führen könnte.

Ziele
Dieses Projekt wird ein Präferenzexperiment mit 1000 zufällig ausgewählten Personen durchführen. Es soll Aufschluss darüber geben, ob die Gesellschaft eine Obergrenze für Kosten kurz vor dem Tod befürwortet und wie hoch diese sein könnte. Den Probanden werden Versicherungsmodelle angeboten, welche sich beispielsweise durch Ausschluss besonders teurer Medikamente für schwere Krankheiten unterscheiden. Aus den Entscheidungen lässt sich, für demografische Gruppen und die Gesellschaft als Ganzes, die Zahlungsbereitschaft ableiten. Zudem wird das Projektteam die Kosten von Verstorbenen im letzten Lebensjahr auf typische Sterbemuster hin untersuchen (z.B. Kosten bei Unfall, bei chronischen Erkrankungen). In der Folge lässt sich bestimmen, wie sich die Anteile dieser Sterbemuster über die Zeit verändert haben. Dies wird Hinweise liefern, ob sich die medizinische Betreuung der Sterbenden in den letzten Jahren verstärkt hat oder ob ältere Menschen heute kurz vor dem Tod in besserem Gesundheitszustand sind als früher.

Bedeutung
Die Ergebnisse liefern Diskussionsgrundlagen für die gesellschaftliche Debatte um Wert und Nutzen teurer medizinischer Behandlungen kurz vor dem Tod. Wünschbar wäre auch die Ausarbeitung möglicher Richtlinien zur Verhinderung versteckter Rationierung.

Direct link to Lay Summary Last update: 18.06.2013

Lay Summary (French)

Lead
Combien coûtent les mesures destinées à prolonger la vie des mourants et combien notre société est-elle disposée à les payer? À l’aide d’une expérience sur la disposition de la population suisse à payer pour des traitements médicaux en fin de vie, ce projet s’efforce de répondre à cette question et à d’autres encore.
Lay summary

Contexte
Combien de traitements médicaux de peu d’utilité sont-ils appliqués avant un décès? Quel est le prix acceptable pour des mesures destinées à prolonger la vie? Et que pense la population suisse des coûts et de la valeur de mesures destinées à prolonger la vie? Ces questions sont difficiles mais il est indispensable que la société se les pose. En effet, jusqu’à un quart de l’ensemble des dépenses de santé ont lieu peu avant le décès et on peut s’attendre à ce que le progrès médical et des traitements plus intensifs fassent encore augmenter les coûts à la dernière phase de la vie. En raison du vieillissement de la population, on peut craindre que les dépenses de santé finissent par devenir inacceptables et que cela entraîne des rationnements douloureux.

But
Ce projet va réaliser une expérience sur les préférences d’un échantillon aléatoire de mille personnes. Il vise à révéler si la société approuve un plafonnement des coûts à l’approche de la mort et quel pourrait être son niveau. On proposera aux volontaires des modèles d’assurance qui se différencient par exemple par l’exclusion de médicaments particulièrement onéreux pour des maladies graves. On en déduira la disposition à payer de groupes démographiques prédéfinis et de la société dans son ensemble. De plus, l’équipe de recherche va étudier les coûts occasionnés au cours de la dernière année de vie de 70 000 personnes décédées, en fonction de différents types de décès (p. ex. coûts à la suite d’un accident, d’une maladie de courte durée, d’une maladie chronique). On pourra ensuite déterminer comment la part de chacun de ces types de décès s’est modifiée avec le temps. Cela permettra de voir si la prise en charge médicale des personnes en fin de vie s’est renforcée ces dernières années ou si les personnes âgées en fin de vie sont aujourd’hui en meilleure santé qu’autrefois. Il s’agit-là de facteurs importants pour évaluer les dépenses de santé futures.

Portée
Les résultats fourniront une base aux débats de société sur la valeur et le bienfait de traitements médicaux onéreux à l’approche de la mort. Il serait aussi souhaitable d’élaborer d’éventuelles lignes directrices pour empêcher des rationnements dissimulés.

Direct link to Lay Summary Last update: 18.06.2013

Lay Summary (English)

Lead
What do life-prolonging measures for the dying cost, and to what extent is our society willing to pay for them? To answer these and other questions, this research project will conduct an experiment on the Swiss population’s willingness to pay for health care expenditures at the end of life.
Lay summary

Background
How many of the medical treatments at the end of life have little benefit? How much should life-prolonging measures be allowed to cost? And what do people in Switzerland think about the cost and value of life-prolonging measures? These are difficult questions that society must face, for up to one-fourth of all health care costs are incurred shortly before death. In addition, it can be expected that medical advances and more intensive treatments will continue to increase the costs in the last phase of life. Due to the aging population, there is a fear that health care expenditures will one day be no longer sustainable and that this could lead to health care rationing, which is a sensitive issue.

Aim
This project will conduct an experiment on the preferences of 1,000 randomly selected persons. It will deliver information on whether society is in favour of defining a ceiling on health care expenditures shortly before death and on how high it might be. The participants will be presented with insurance models that differ in, for example, their exclusion of especially expensive medications for serious illnesses. Based on the participants’ decisions, we will derive the willingness to pay for health care expenditures of predefined demographic groups and the Swiss population as a whole. In addition, the research team will examine the costs of over 70,000 deceased persons in their last year of life with regard to typical patterns of dying (such as costs connected with accidents, brief illnesses, chronic diseases) and then determine how the percentages of these patterns of dying have changed over time. This will provide an indication of whether medical care of the dying has increased in recent years or whether elderly people today are in a better state of health shortly before death. For assessing future health care expenditures, both of these findings are important factors.

Significance
The results of this study will underpin the debate on the value and benefits of expensive health care measures at the very end of life. They might also be used in compiling guidelines to help the prevention of hidden rationing.

Direct link to Lay Summary Last update: 18.06.2013

Responsible applicant and co-applicants

Employees

Publications

Publication
Cost trajectories from the final life year reveal intensity of end-of-life care and can help to guide palliative care interventions
von Wyl Viktor, Telser Harry, Weber Andreas, Fischer Barbara, Beck Konstantin, Cost trajectories from the final life year reveal intensity of end-of-life care and can help to guide palliative care interventions, in BMJ Supportive & Palliative Care.

Collaboration

Group / person Country
Types of collaboration
Institut für Sozial und Präventivmedizin, Universität Bern Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results

Scientific events

Active participation

Title Type of contribution Title of article or contribution Date Place Persons involved
Swiss Health Economics Workshop Talk given at a conference Do healthcare expenditures at the end of life reflect preferences of the Swiss population? 11.09.2015 Luzern, Switzerland Telser Harry;
iHEA Talk given at a conference Do healthcare expenditures at the end of life reflect preferences of the Swiss population? 15.07.2015 Milano, Italy Fischer Barbara;
Seminar Applied Health Economics Talk given at a conference Do healthcare expenditures at the end of life reflect preferences of the Swiss population? 08.12.2014 Luzern, Switzerland Fischer Barbara;
Workshop III on the Evaluation of Ultrarare Diseases (URD Workshop) Talk given at a conference Social Preferences: How to Measure? 13.11.2014 Amsterdam, Netherlands Telser Harry;
German VaQ Workshop Talk given at a conference Do high health care expenditures at the end of life reflect preferences of the Swiss population? 12.09.2014 Berlin, Germany Telser Harry;


Knowledge transfer events

Active participation

Title Type of contribution Date Place Persons involved
Meeting of the National Fund Program 67, End of Life Talk 02.10.2015 Sursee, Switzerland Fischer Barbara; Beck Konstantin; Telser Harry;


Abstract

It has long been known that health care expenditures tend to rise with older age and that costs have grown disproportionally among the elderly (i.e. individuals aged 65 or more). Moreover, the introduction of new, very expensive drugs with sometimes very high costs per quality adjusted life years (>100’000 US$) and low gains in additional life years (months or even weeks) further fuel the growth of health care expenditures. Because demographers also predict significant changes in age structures of Western societies - with higher expected shares of old individuals and higher incidences of age-associated diseases (including cancer) - this has raised concerns that current systems of health care financing will soon reach their limits, with potentially harsh and unfair outcomes such as limited access to novel treatments or rationing. A number of studies have identified end of life costs as a substantial contributor to overall health care expenditures among older individuals. Yet not the full magnitude of all end-of-life costs may be inevitable. The observation of vast regional cost variations and associations with hospital bed density also suggest supplier-induced components to end-of-life health care expenditures. At the same time our society has a tendency to avoid discussions about the utility of certain expensive medical treatments for terminally ill individuals. What is more, scientific data for medical deci-sion making in end-of-life situations is scarce. In particular, there is very little information about the amount of money individuals (both the patients and members of the society) would be willing to spend and whether the sometimes very high end-of-life costs are really justified in their view. With this project we aim to add to the scientific debate about expenditures and benefits at the end of life and to promote the discussion in our society by proposing a framework for medical decision making. We propose three interlinked projects. In the first project (work package 1) we will analyse cost data from decedents to identify specific patterns (i.e. cost trajectories) reflecting different underly-ing morbidity patterns (e.g. chronic morbidity leading to death, sudden death without prior ex-tended morbidity). Not only will this approach based on a novel statistical method (trajectory modelling) provide new insights into end-of-life costs, the information gleaned from this analysis will also be used for the second project (work packages 2 - 5), where we would like to elicit the willingness to pay from 1000 representatively chosen Swiss individuals with regards to end-of-life treatments. The results from work package 1 will help to design a case study, which will be em-ployed in a discrete-choice experiment to elicit the preferences of the general population. The work packages (WP) 2 - 5 describe the different stages of the survey staring with the design of the experiment (WP2), a pre-test phase and the conduct of the actual experiment (WP3), the data cleaning and preparation for analysis (WP4), and the econometric analysis of the data set (WP5). The third project (WP6) includes the execution of a cost-benefit analysis by combining the cost data derived from WP1 with the willingness-to-pay information from the discrete-choice experi-ment. In particular, we will study whether and when the costs of end-of-life treatment have ex-ceeded our society’s willingness to pay in the past and make projections into the future on the basis of expected demographic changes and costs. By carrying out the research outlined in this proposal we hope to obtain a reliable picture of in-dividual preferences for end-of-life health care expenditures and of the societal willingness to pay. Moreover, the information learned from these projects will guide us in establishing a frame-work and a societal setting, within which individual decisions - given fair and appropriate con-straints - can be made. Furthermore, we will attempt to derive clear and applicable propositions for legislators and medical doctors and to promote and inform the public debate about end-of-life expenditures.
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