NOT FUNDING TREATMENT FOR OLDER ADULTS WITH MEDICARE DOLLARS WHEN

THERE IS NO HOPE FOR REMISSION (PRO)

Lori KatterhagenKimberly 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

TopicElderly 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” WordRATIONINGFrom 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

DefinitionsREMISSION:

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

Facts80-85% 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).

FactsDeaths

OthersMedicare Bene-ficiaries 65+

ProblemMedicare 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

HistoryCallahan - 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 FamilyANA 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 CostsAdvancement 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 TheoriesConsequentist 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 EthicsThe 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 considerationsDeep 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/ mortality

Lack of promotion of Living Wills and Healthcare Power of Attorney

Alternate StrategiesUniversal Healthcare Responsible Use of Medical Technology/BillingPalliative CareLessons learned from other countries

Hong KongEnglandCanada

RESULTSCourse of Action

Ethical Justification

Course of Action: Universal Healthcare with Controlled RationingDevelop 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 CountriesHong KongEnglandCanada

Controlled Rationing must have’sBasic healthcare should be offered for all- to a

limitPromotion of Family practice doctors that

specialize in gerontologyDefine treatments for Quality of Care vs.

Prolonging Lifetime 1

Early Detection of Palliative Care candidatesDevelop protection for physicians/APN

1 Prager, 2008

Callahan’s 4 procedural premisesRationing needs to be done by

policyPolicy must be set by democratic

processPolicy must be carried out in a

transparent wayThere should always be a

provision for appeal

Ethical implications

The END

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