For the last few decades, the share of Medicare costs incurred by patients in their last year of life has stayed at about 28 percent, said Dr. Gail R. Wilensky, a senior fellow at Project HOPE who previously ran Medicare and Medicaid. Thus end-of-life care hasn't contributed unduly of late to Medicare's problems. But that doesn't mean it shouldn't be part of the solution. "If you take the assumption that you want to go where the money is, it's a reasonable place to look," Dr. Wilensky said.Rationing health care is, of course, hardly a new idea, but this particular debate never gets much attention. One of the concepts implicit here—though not mentioned in Altman's piece—is the notion of quality-adjusted life years (QALYs), a metric that help us compare the cost-effectiveness of certain treatments. Some treatments obviously are very cost-effective at adding QALYs, like vaccinations. Others—like the sort of expensive "Hail Mary" treatments used on seniors at their lifes' end—may cost more and yield fewer QALYs. Thanks to shiny new medical technology, we can extend people's lives longer and longer, but you don't get quite as many QALYs for your buck. You can think of it—and I saw this graphed out somewhere in Health Affairs once—as a supply curve. The U.S. is very high up on the curve, higher than any other country, and pays a lot more for each additional QALY, but in the end doesn't get very many more QALYs for its buck.
End-of-life care may also be a useful focus because, in some cases, efforts to prolong life may end up only prolonging suffering. In such cases, reducing pain may be a better use of resources than heroic attempts to save lives.