NOT FUNDING TREATMENT FOR OLDER ADULTS WITH MEDICARE DOLLARS WHEN

THERE IS NO HOPE FOR REMISSION (PRO)

Lori Katterhagen

Kimberly Lai

DNP Students at University of San Francisco

OUTLINE

Topic

Intro Definitions Medicare Facts The Problem History

Analysis Professional Nursing Goals Stakeholders Moral Theories Alternate Strategies

Results

Topic

Elderly patients who have little chance of remission should not be given any treatments that are covered by Medicare

What IT IS NOT: This is not a debate where both elderly and nonelderly have the SAME medical problem requiring the same treatment

The Dirty “R” Word

RATIONING

From President Lyndon Johnson in 1965 referring to Medicare : “the fools had to go projecting down the road five or six years, $400 million's not going to separate us friends when it's for health"

Why We Must Ration Health Care- New York Times, Peter Singer- July 15, 2009

Definitions

REMISSION: Chronic disease that cannot be cured, only

managed A state or period during which the symptoms of a

disease are abated <cancer in remission after treatment>1

ELDERLY: United Nations- those aged 60 and over2

1 http://www.merriam-webster.com/medical/remission2 http://www.un.org/en/development/desa/news/population/major-rise-in.html

Definitions (cont.)

MEDICARE: health insurance for the following-People 65 or olderPeople under 65 with certain disabilitiesPeople of any age with End-Stage Renal Disease

(ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)

(Centers for Medicare & Medicaid Services, n.d)

Definitions (cont.)

Rationing; to distribute as rations; to distribute equitably; to use sparingly1

Just rationing policies would distribute resources according to criteria that respect human dignity and the common good—presuming an equality of persons that may nevertheless take into account differences in social responsibility2

1 http://www.merriam-webster.com/ration2 Ascension Health, 2012

Facts

80-85% of deaths in the US are Medicare beneficiaries age 65+1

Most of those die from chronic conditions (heart disease, COPD, CVA, DM, Alzheimer’s, renal failure)1

Elderly will make up 22% of the world’s population by 2045, comparing to 11% in 2009 and 8% in 1950 2

Elderly represent 13% of population but consume 35% of health care cost3 1Kass-Bartelmes & Huges, n.d.

2http://www.un.org/en/development/desa/news/population/major-rise-in.html

3. Fleck, L. (2010).

Facts

Deaths

OthersMedicare Bene-ficiaries 65+

Problem

Medicare is has no cap in spending and paying Millions of dollars on procedures that do not make sick people better1

Medicare spending too much money on treatments for chronically ill patients 2

Demographics project there could be 1.1 million centenarians by 2050.  According to Social Security Administration, in 2008, 2,114 of 104-year olds were receiving Medicare benefits 3

Medicare spending is escalating 1993 - $150 billion 2009 - $503 billon 2018 (est) - $932 billion3,4 1 Nather, 2010

2 Alemayehu &Warner,20043 Hartocollis, 2008

4 Fleck, 20105 Potetz, Cubanski, &Neuman, 2011

Problem (cont.)

By 2045, the elderly will outnumber children for the first time in the world 1

In US, per capita lifetime expenditure is $316,600, a third higher for females ($361,200) than males ($268,700). Two-fifths of this difference owes to women's longer life expectancy. Nearly one-third of lifetime expenditures is incurred during middle age, and nearly half during the senior years. For survivors to age 85, more than one-third of their lifetime expenditures will accrue in their remaining years 3

2000, 50,454 in US are 100yo +.  In 2010, 53,364 are 100yo + 4

If we don’t start rationing healthcare to some elderly, we would have to be willing to tolerate significant injustices in our healthcare system 5

1United Nations- Department of Economic and Social Affairs,2009 4Howden & Meyer

5Fleck, 2010

History

Callahan - in the 1980’s introduced  the concept that those people that reach a “natural life span” of 75-80 should be denied expensive life saving treatment because they no longer had a moral claim

Rationing occurs already, just not managed or structured. Done irrationally at physician discretion (Fleck,2010)

Insurance companies and Medicare are limiting tests, based on age

Since 1993, Oregon’s Medicaid program has limited the amount of procedures covered (Smith, 2011)

HOW FAR WOULD WE GO?

IS THERE A LIMIT?

Issues Related to Professional Nursing Goals

Respect/Quality of Life

Autonomy of Patients and/or Family’s Wishes

Veracity/Education of Rise in Medical Costs

Justice

Respect/Quality of Life

Decisions should be made in best interest of patient

People with chronic diseases (heart disease, COPD) are not well informed by physicians and advance planning are not done early enough

People with chronic conditions go through a series of hospitalization, declines and recoveries, until death.

People who die from chronic conditions have a more difficult time at the time of death than those dying from cancer (because cancer has a trajectory, and patients are well informed)

When patients are hospitalized for chronic incurable diseases, medical treatments do not cure underlying illness, just resolves any immediate emergencies.  Thus, prolonging the patient’s life, and possibly suffering.

(Kass-Bartelmes & Huges, n.d)

Autonomy of Patient and/or Family

ANA Code of Ethics- patients have a moral and legal right to determine their own care (ANA, 2001)

After a series of hospitalization, patient may become too weak and incapable of speaking for themselves.

At this point, family and physicians become patient’s surrogate.

(Kass-Bartelmes & Huges, n.d)

Veracity/Rise in Medical Costs

Advancement of medical technology leads to rise in medical costs that patient may not be aware of.

Public demand and consumer expectations are higher, and more healthcare manpower is needed

Government needs to be open and honest about costs, and not start putting more cost on the patients and public

(Health and Medical Development Advisory Committee, 2005)

Justice

If it is the younger generation who pay the taxes used to care for the old, are there some limits to what they should be asked to pay? Especially as the baby boomers age and the cost of their care falls on fewer people

Is it just that taxes rise for the younger generation in efforts to raise funds to support the old and now threaten their own ability to care for their families and children

Where do we draw that line?

We need to focus on the common good, because we all will deal with illness, aging and death

Stakeholders

Medicare beneficiaries: People 65 or older People under 65 with certain disabilities People of any age with End-Stage Renal Disease (ESRD)

(permanent kidney failure requiring dialysis or a kidney transplant)1

Federal Medicare programs

State medical supplemental programs

Private insurances

Families

Every one of us in this room

1 Centers for Medicare & Medicaid Services, n.d

Moral Theories

Consequentist theory - focus is on what will produce the best outcome for the most people. If focus really were on the greater good, several experts make some suggestionElderly should not receive treatments to extend their

lives at the expense of those who have not lived out a normal life span (Andre & Velasquez, 2008)

We have a duty to help young people to become old people, but not to help old people become still older indefinitely (Callahan, 2008)

Policies regarding ethical issues should be “made democratically, universally and equally binding” (Pelligrino, 2002)

Moral Theories (cont.)

Utilitarianism- maximizes overall happiness (not individual) and looks for good outcomes after the fact; critiques social injustices

“Rationing will make us sicker for a time, but it is a necessary painful cure to make us financially healthy in the long run” (Callahan, pg 12,2012)

A question of Virtue Ethics

The poor and vulnerable have a right to BASIC health care, but cannot provide due to high spending on Medicare.

Good stewardship for the whole community, not just the old

Cultural considerations

Deep American belief that there is unlimited medical capabilities (Callahan, 2012)

Very successful at preventing or decelerating the effects of aging (Callahan, 2012)

Fear of dying/ mortalityLack of promotion of Living Wills and Healthcare

Power of Attorney

Alternate Strategies

Universal Healthcare

Responsible Use of Medical Technology/Billing

Palliative Care

Lessons learned from other countriesHong KongEnglandCanada

RESULTS

Course of Action

Ethical Justification

Course of Action: Universal Healthcare with Controlled Rationing

Develop an approach that emphasizes patient and physician education about what treatments are helpful and what is not, specifically focusing on those treatments that help improve quality of life, not just lifetime (Prager, 2008)

Policy makers and government need to sit at the table and redefine what constitutes reasonable and necessary

Lessons Learned from Other Countries

Hong Kong

England

Canada

Controlled Rationing must have’s

Basic healthcare should be offered for all- to a limit

Promotion of Family practice doctors that specialize in gerontology

Define treatments for Quality of Care vs. Prolonging Lifetime 1

Early Detection of Palliative Care candidates

Develop protection for physicians/APN

1 Prager, 2008

Callahan’s 4 procedural premises

Rationing needs to be done by policy

Policy must be set by democratic process

Policy must be carried out in a transparent way

There should always be a provision for appeal

Ethical implications

The END

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American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: Author.

Andre, C., & Velasquez, M. (1990). Aged-based health care rationing. Issues in Ethics, 3 (3).

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