Protecting Older People While Managing Their Care

Two papers in this issue of the Journal of the American Geriatrics Society address the application of managed care strategies to older patients. Pearlman et al.1 tracked healthcare expenditures over 18 months to demonstrate the complex temporal patterns of these expenses. Pacala et al.2 assessed the validity of one instrument —the Pra —in predicting future health resource use. The interest in health resource utilization by the older persons that these two studies represent is consistent with a growing focus on health related expenditures by older patients. It is well known that the use of medical services becomes more intense as death approaches. For example, the 6.4% of Medicare beneficiaries who died in 1994 accounted for 20.6% of the total Medicare payments.3 Those who died cost Medicare $15,761 per person while those who survived the year cost only $4,131 per person. Changes in health systems further increase the concern over costs. The rise of capitated payment systems places the onus of cost control on health delivery rather than on health finance organizations. In the case of Medicare, for example, establishing prepaid health maintenance organization shifts much of the challenge of cost control from the federal government to the managed care organization that must provide undefined services for a defined price. Because health delivery organizations have more direct control over health care services than do payer organizations, this shift in the site of cost control may result in greater impact on health care than before. This shift in responsibility coupled with the increasing prevalence of managed care organizations enrolling or targeting older people demands that the methods that may be used to control expenditure be examined carefully. It is not enough—even though it is important —to study the finances of health care for older people; we must also examine the consequences of the application of that knowledge in current and emerging healthcare systems. Whereas the older population, many of whom have multiple medical problems, may, at least in theory, benefit from the coordinated care offered by managed care organizations,4 they are also the population most vulnerable to abuse. See also p 550 and p 614 Some of the reasons for this vulnerability are obvious; others are more subtle. The general sense that older people consume a disproportionate share of resources makes them a natural target for cost reduction schemes. The enthusiasm for this approach is bolstered by other characteristics commonly attributed to older people.5 Too often, frail or minimally cognitively impaired older persons are assumed to be incompetent to make rational healthcare choices so that substituted judgment may be overused. Assumptions that all older persons have less quality of life than do younger persons, even in the absence of debilitating conditions and without assessment of the quality of life from the patient's perspective, may lead to the bias that less short- and long-term benefits result from in providing care to older people than to other groups. The issue of longevity is likewise complex. Older patients who are healthy or who have some disorders may expect to live longer than younger patients with certain conditions. And it is often assumed that aggressive treatment is either less effective or less well tolerated in older than in younger patients; expensive procedures may be withheld in the name of reducing risk and avoiding futile efforts.6 These assumptions, however invalid when applied uniformly to older people as a group, may facilitate the withholding of needed care. In managed care organizations, cost control in providing health care to older persons may be implemented by several means. Some of these are used in younger populations. Three concerns that we will consider briefly here include actions designed to limit enrollment of older people, the inappropriate use of advance directives, and the selective use of appropriateness criteria to limit care. First, managed care organizations may selectively discourage older adults from enrolling or, more particularly, re-enrolling in health plans. Discouraging re-enrollment is important to reduce the fiscal risk of patients who “age in place,” i.e., members who initially enrolled when younger but stayed with the health plan until they reach advanced ages. Numerous overt and covert mechanisms exist for each, including the strategic selection of the content, timing, and medium of advertisement, location of care sites, etc. More problematic from an ethical perspective are activities that subvert the beneficial effects of advance planning functions from the patient to the managed care organization.7,8 Promoting advance directives and offering full information as to limits as well as benefits of care options, for example, are designed to protect patients' autonomy in making end of life decisions and to “protect” them from the presumed paternalism and overzealousness of the health care system. Movements supporting euthanasia and physician-assisted suicide are likewise intended to expand the options available to patients to decide for themselves how they will die. However, the managed care organizations, as well as the patient, have a stake in these decisions. Care forgone is cost forgone. Linking physician payment to resource utilization adds further to this chain of possible, if not inevitable, conflicts of interest. Here, too, the methods for influencing patients' decisions may be overt or subtle. Altering the timing, content, or mode of presentation of information concerning end-of-life choices may be much less direct but equally effective in influencing decisions encouraging inexpensive palliative care over more costly life-maintaining services. It is hard to engage in meaningful and informed advanced planning when the client cannot understand what choices of care are truly available because of the complexity as well as the vagueness of managed care contracts. Attitudes of and incentives for physicians may also alter patients' decisions and determine whether or not they are fulfilled. In the SUPPORT study,9 for example, physicians performed cardiopulmonary resuscitation on only 58% of patients requesting it. A recent study reported that 60% of physicians in Oregon thought that physician-assisted suicide should be legal in “some cases.”10 The net result may be an unholy alliance between managed care and managed dying.11 A third area of concern is in the application of concepts of appropriateness and futility to older patients as a means of cost control. Both are vague concepts, subject to debate in general and uncertainty when applied to a particular case. Whether a test is appropriate or inappropriate or a procedure is futile is subject to much uncertainty for many reasons.12 The assessment of the appropriateness of most procedures is limited for example, by the limited information available as to the impact of much of what we do on patient outcomes. Defining what is futile is even more difficult because of this lack of knowledge as well as the inherent subjectivity of the term; assigning futility to a chance of benefit of less than one in one hundred or one in one thousand can only be accomplished by discussion and not by study. Both are also highly dependent on the specific situation in which they are used; what is inappropriate or futile for one patient in one circumstance may be worthwhile for another or in another situation in which the goals of care are different. The limits of both of these concepts may lead to implicit as well as explicit rationing or withholding of care for older persons. While care for all patients may be restricted by tightening the definition of appropriateness or loosening that of futility, older people are at greater risk than are younger cohorts. This risk is the result of many of the biases listed previously, e.g., the presumed lower quality of life and longevity and the higher risk of procedures in older adults. Although these presumptions are unfounded when applied to older people as a group, they do form a basis for withholding care, especially when reinforced by financial motivations. We cannot say that any of these actions occur commonly. Our concern is that we are moving rapidly into a health system in which the various dynamics are such that they might occur. The consequences are so great that even the possibility requires that the issues be discussed and safeguards be proposed for the protection of our aging parents today and ourselves tomorrow.