Lori Katterhagen Kimberly Lai DNP Students at University of San Francisco

1. 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

2. OUTLINE • Topic • Intro • Definitions • Medicare Facts • The Problem • History • Analysis • Professional Nursing Goals • Stakeholders • Moral Theories • Alternate Strategies • Results

3. 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

4. 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

5. 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 1http://www.merriam-webster.com/medical/remission 2http://www.un.org/en/development/desa/news/population/major-rise-in.html

6. Definitions (cont.) • MEDICARE: health insurance for the following- • 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) (Centers for Medicare & Medicaid Services, n.d)

7. 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 dignityand the common good—presuming an equality of persons that may nevertheless take into account differences in social responsibility2 1 http://www.merriam-webster.com/ration 2 Ascension Health, 2012

8. 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).

9. Facts

10. 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 1Nather, 2010 2Alemayehu &Warner,2004 3 Hartocollis, 2008 4 Fleck, 2010 5 Potetz, Cubanski, &Neuman, 2011

11. 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 are100yo +.  In 2010, 53,364 are100yo + 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

12. 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)

13. HOW FAR WOULD WE GO? IS THERE A LIMIT?

14. 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

15. 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)

16. 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)

17. 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)

18. 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

19. 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

20. 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 suggestion • Elderly 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)

21. 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

22. 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/ mortality • Lack of promotion of Living Wills and Healthcare Power of Attorney

23. Alternate Strategies • Universal Healthcare • Responsible Use of Medical Technology/Billing • Palliative Care • Lessons learned from other countries • Hong Kong • England • Canada

24. RESULTS • Course of Action • Ethical Justification

25. 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

26. Lessons Learned from Other Countries • Hong Kong • England • Canada

27. 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

28. 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

29. Ethical implications

30. The END

31. Reference • A conversation with Leonard Fleck, PhD: public deserves honest debate on rationing. (2010). Managed Care, 19(8), 34. • Alemayehu, B., & Warner, K. (2004). The lifetime distribution of health care costs. • Health Services Research, 39(3), 627–642. doi: 10.1111/j.1475-6773.2004.00248.x • 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). • Ascension Health. (2012). Issues and concepts: Rationing. Retrieved from http://www.ascensionhealth.org/index.php?option=com_content&view=article&id=198&Itemid=172 • Callahan, D. (2012). Must We Ration Health Care for the Elderly? Journal of Law, Medicine & Ethics, 40(1), 10-16. doi:10.1111/j.1748-720X.2012.00640.x • Callahan, D., & Prager, K. (2008). Medical care for the elderly: Should limits be set? Virtual Mentor, 10(6). 404-410. • Centers for Medicare & Medicaid Services. Medicare Basics. Retrieved from http://www.medicare.gov/Pubs/pdf/11034.pdf • The Center for Public Integrity. Retrieved from http://www.publicintegrity.org/2010/11/07/2334/medicare-entitlement-out-control • The Council on Catholic healthcare of the Michigan Heath and Hospital Association. (2008). Position statement on managed care. Retrieved from http://www.ascensionhealth.org/assets/docs/CCHC_Position_Statement_on_Managed_Care.pdf • Department of Economic and Social Affairs. (2010). Major’ rise in world’s elderly population: DESA report. Retrieved from http://www.un.org/en/development/desa/news/population/major-rise-in.html.

32. Reference • Easley, C. & Allen, C. (2007). A critical intersection: Human rights, public health nursing, and nursing ethics. Advances in Nursing Science, 30(4), 367-382. • Fleck, L. (2010). Just caring: In defense of limited age-based healthcare rationing. Cambridge Quarterly of Healthcare Ethics, 19, 27-37. • Grace, P. J. (2009). Nursing ethics and professional responsibility in advanced practice. Boston, MA: Jones and Bartlett Publishers. • Hartocollis, A. (2008, July 18). Rise seen in medical efforts to treat the very old. The New York Times. Retrieved from http://www.nytimes.com/2008/07/18/health/18old.html?pagewanted=all • Health and Medical Development Advisory Committee (2005). The need for change. Retrieved from http://www.fhb.gov.hk/beStrong/files/consultation/chapter1_eng.pdf • Health & Community. (2010, January 27). Cataract surgery waiting list reviewed. Retrieved from http://archive.news.gov.hk/isd/ebulletin/en/category/healthandcommunity/100127/html/100127en05004.htm • Howden, L.M., & Meyer, J.A. (2011). Age and sex composition: 2010. United States Census Bureau. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf • Kass-Bartelmes, B.L., & Hughes, R. (n.d.). Advanced care planning: Preferences for care at the end of life. Agency for Healthcare Research and Quality, 12. • Lauridsen, S., Norup, M., & Rossel, P. (2007). The secret art of managing healthcare expenses: investigating implicit rationing and autonomy in public healthcare systems. Journal Of Medical Ethics, 33(12), 704-707. • Nather, D. (2010, November 7). Medicare: An entitlement out of control. Retrieved from http://www.publicintegrity.org/2010/11/07/2334/medicare-entitlement-out-control • Pellegrino, E. (2002). The physician's conscience. Fordham Urban Law Journal. 30 (1), 221-244. • Potetz, L., Cubanski, J., & Neuman, T. (2011). Medicare spending and financing: A primer. The Henry J. Kaiser Family Foundation. • Singer, P. (2009, July 19). Why we must ration health care. The New York Times. • Smith, W. J. (2011, January 31). About those death panels . . . The very real threat of government health care rationing. The Weekly Standard, 16(19). Retrieved from http://weeklystandard.com/articles/about-those-death-panels_536874.html