Congressional Newsletter
Monthly updates to Congress on RAND's work in health policy

Improving Care at the End of Life

Elderly woman

Americans live longer, healthier lives than ever before. But this longer life expectancy also poses new challenges, including the financing of the health care needs of Americans as they grow older. These challenges are the reason there have been many proposals in Congress to ensure the solvency of Medicare. However, nearly all elderly Americans suffer from multiple, progressive, and eventually fatal chronic illness at the end of life. As the baby-boom generation ages, supporting elderly persons with serious chronic illness is likely to become a dominant issue for health care in the next half-century. The looming financial consequences of aging are also ominous. Long-term care costs are expected to rise sharply, from $137 billion in 2000 to an estimated $207 billion by 2020 and $346 billion by 2040.

The health care system has been slow to adapt to the needs of this growing elderly population. The existing system generally operates on the assumption that living and dying are categorically distinct and that medical practitioners must either (1) apply aggressive conventional care to try to extend or save the person's life or (2) accept death and provide palliative care.

Today, however, health care professionals know that many chronically ill elderly have ambiguous medical prognoses: They may be sick enough to die on any given day or they may live for many years. Therefore, the symptom management and support services of palliative care are no longer restricted to a relatively short and easily recognizable end-of-life period—and it is no longer appropriate to associate the beginning of palliative care with the cessation of conventional medical care. Instead, frail or chronically ill elderly patients nearing the end of life typically require a mix of various kinds of care.

Researcher Joanne Lynn identifies several options for changing the U.S. health care system to meet the needs of chronically ill elderly patients. These steps include addressing the looming shortage of caregivers; reallocating federal financing to promote continuity of care across different settings; paying more attention to the wishes of elderly people, who often prefer reliable nursing care and family support to expensive medical treatment; and defining priorities for developing reliable end-of-life care, which will require better data about the changing epidemiology of eventually fatal chronic illness.

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Research on Improving Care for Heart Failure Seldom Affects Practice

Blood pressure

Clinically tested improvements have exerted little influence on Medicare policy. One example would be in regard to chronic heart failure.

Chronic heart failure affects about 5 million people in the United States. The disease is characterized by a weakening of the heart, which gradually loses its ability to pump blood. There is no cure, although many treatments can slow its progression and reduce patients' suffering. Chronic heart failure mostly affects the elderly. It is the most common reason that Medicare recipients are hospitalized and represents the diagnosis that generates the most costs for Medicare. A number of research projects have tested methods to improve care for patients with chronic heart failure. However, patients rarely benefit from this research because the results are seldom translated into routine clinical practice or policy changes. Analysts examined 15 U.S.-based research projects that demonstrated ways to improve the health of patients with heart failure. The study found that only two of these projects continued providing innovative services to their own patients at the conclusion of their research, even when that research had demonstrated substantial improvements. Of the 15 projects, 13 ended after demonstrating success, primarily because of financial constraints.

In 2004, Medicare reform legislation directed federal officials to adopt a system to improve care for chronic heart failure. But the strategies outlined in the legislation–primarily telephone-based management services targeting huge numbers of patients–have not been tested in clinical trials. It is therefore uncertain whether these measures will improve care or reduce spending.

The study proposed steps for tying health services research more closely to practice and policy. For example, researchers could ensure that published results discuss prospects for a wider implementation of insights gained from research. Consumer and professional organizations could play a more active role advocating for greater evidence-based input into coverage and payment policy. Finally, policymakers could make their key factual questions known to researchers, and funding agencies could give priority to research designed to address these questions.

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Adolescents Who Listen to Degrading Sexual Lyrics Have Sex Sooner

Boy wearing headphones. Photo by (c) Kuzma.

The more time adolescents spend listening to music with sexually degrading lyrics, the more likely they are to initiate intercourse and other sexual activities. This holds true for boys and girls as well as for whites and nonwhites.

News Release | Abstract


Michael Rich
Executive Vice President

Shirley Ruhe
Director, Office of Congressional Relations

Kristy Anderson
Health Legislative Analyst

RAND Office of Congressional Relations
(703) 413-1100 x5180


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