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Experts Dispute Remark That Living Wills Save Money

By Ceci Connolly
Washington Post Staff Writer
Friday, May 6, 2005; Page A09

Health and Human Services Secretary Mike Leavitt said this week that encouraging senior citizens to write living wills could dramatically reduce Medicare's skyrocketing health care costs.

But a large body of scientific data -- including an article co-written by the Bush administration's Medicare chief -- offers little or no evidence that living wills or hospice care lower medical bills.

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In response to a question, Leavitt told hospital administrators Monday he was weighing a proposal to have doctors incorporate into their consultations with Medicare patients a conversation about the value of writing detailed instructions for end-of-life treatment, known as a living will or advance directive.

"It may be that we could build into Medicare a means by which there was a consultation as part of the Medicare physical where that decision could be discussed and potentially made and . . . it would not just save families anguish but would likely save the system a remarkable amount of money, allowing that money to be spent in other ways and in other places," he said, according to a transcript by the Associated Press. Leavitt said the idea was suggested to him by a member of Congress.

The trouble is, "there is no evidence that suggests that is true," said Joan Teno, professor of community health at the Brown Medical School.

"I once believed that. It makes sense," said Lawrence J. Schneiderman, a professor of family and preventive medicine at the University of California at San Diego, who has studied end-of-life issues extensively. "When we actually tested it, it didn't" save money.

About one-third of Medicare's $295 billion budget this year will go for care provided in the final year of life, a fact that has prompted many policymakers to look for ways to trim those costs.

"I'm a big advocate of living wills because they give people the power to make decisions," said Ezekiel Emanuel, an authority on end-of-life care and the creator of a widely recognized advance directive form. "I am a not big advocate of living wills because they save money."

In a series of academic articles, the three researchers and others outlined several reasons why having an advance directive does not have a significant impact on medical spending. Many patients sign documents with limited or conflicting instructions; many do not include a do-not-resuscitate order; some physicians refuse to comply with the instructions; and, contrary to popular perception, not every living will calls for less aggressive or less costly treatment.

Another common misperception is that care in the final months of life is expensive largely because of modern technology such as breathing machines, Teno said.

"Those costs are not for the" intensive care unit, she said. More of the expense comes in "custodial care" such as round-the-clock nurses, therapists and pain medication.

Leavitt's aides yesterday played down his comments and said there are no plans to change Medicare policy.

"The point he was making is living wills are something families should consider to save themselves anguish in times of tragedy," HHS spokesman Kevin Keane said.

Later, Keane said Leavitt "regrets if the comment was inaccurate. He did not intend to link living wills to the issue of costs."

Keane refused to identify the lawmaker who proposed the living will idea to Leavitt, calling it a private conversation.

Emanuel, who oversees the bioethics program at the National Institutes of Health, said he was not speaking in his official capacity. However, in his previous work he has advocated a one-time consulting payment to doctors for discussing advance directives with their Medicare patients.

"Not because it would save Medicare money," he said, "but because it allows the conversation to occur."

Mark McClellan, administrator of the Centers for Medicare and Medicaid Services, was co-author of a study in the Archives of Internal Medicine in 2002 in which researchers concluded that increased use of hospice care -- as opposed to a hospital -- near the end of life did not reduce medical costs.

"Despite dramatic changes in the health care system during the past decade, the economics of dying remain relatively unchanged," they wrote.


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