1. A. Sultan, December 2001 Utilization of Physician Services at the End of Life: Differences between U.S. and Canada Issue: Increased health care expenditure? Medical resources devoted to caring for people in their last year of life --- may be !! Analyzed physician services (by clinical types) used by elderly decedents and survivors, also compared between the two countries

2. Data Sources Physician claims data for 1992 U.S. --- 1% random sample of beneficiaries over age 65 from Medicare data --- 282,590 people BC and Quebec -- utilization of their entire population in that age group --- BC = 431,600 Quebec = 784,100

3. Definitions Decedents -- Those who died in the six months prior to December 31, 1992 Survivors -- Those who lived past December 31, 1992 Decedents --- U.S. = 7,074 people BC = 8,822, Quebec = 16,461

4. Physician Services 1. Evaluation and Management Services (non-laboratory, nonendoscopic diagnostic test, hospital/emergency room visits etc.) 2. Procedures -- ((cardiovascular, orthopedic(knee replacement), endoscopies)) Because of differences in fee levels --- Relative Value Units (RVUs) to measure medical resources

5. Relative Value Units RVUs RVU = (TW) (1+RPC) (1+AST) Where; TW = total work input by physician RPC = Index of relative speciality practice cost (malpractice premiums) AST = Index of amortized value for the opportunity cost of specialized training

6. For remaining Canadian codes -- approximate method Ratio r ij = F ij / RVU ij Where; F = provincial fee for a service I = type of service category, j= province Weighted average, R j = € r ij W ij Where, Wij is the proportion of RVUs that this code accounts for in type of service category j in Medicare data

7. For remaining Canadian codes R j (weighted average of ratios) represents a measure of Canadian dollars per RVU RVU jg = E jg /R j where, E jg is total Canadian dollars for a service for a group g (decedents/survivors) in a province RVUs for survivors --- U.S. directly from Medicare sample For BC and Quebec

8. N a M a = N d M d + N s M s Where; N = number of elderly M = mean RVUs d = decedents, s = survivors, a = all elderly FACTORS MIGHT INFLUENCE RESULTS ----- Constrained resources in Canada like (open heart surgery) Unconstrained Resources in Canada --- primary care ---comparable in U.S.

9. Factors………. Practice style -- difference in treatment Difference in surgical procedure payments - pre-operative and post-operative visits, similar in U.S. and BC but more in Quebec In Quebec, elderly spent too much services- more frequent visits and longer length of stay In Quebec, Physician can bill for up to 3 hospital visits per day for a single patient

10. Average RVUs for decedents and survivors-total physician services

11. Average RVUs for decedents and survivors - evaluation & management services

12. Average RVUs for decedents and survivors -- procedures

13. Average RVUs for decedents and survivors -- consultations

14. Average RVUs for decedents and survivors -- major cardiac

15. Concluding remarks Increased health expenditure ? Elderly decedents use more medical resources than survivors ---U.S. and Canada Evaluation and management services used by decedents and survivors in U.S. and BC are comparable but more in Quebec Volume of services used by decedents increased as death approached…??…LESS ALLOCATION OF RESOURCES FOR ELDERLY………?????????????????