New Era of Healthcare Reform: Need for Advocacy and Cost Containment

This issue of Clinical Geriatrics features articles that I hope you will enjoy reading as much as I have: “Hyperlipidemia in Older Adults,” “Predicting Survival From In-Hospital CPR,” and “Management of End-Stage Renal Disease in the Older Adult.” As I was reading these articles in sequence, however, I kept thinking of the healthcare debate and the cost of providing care to individuals in their last decade or less of life. Whether someone has hyperlipidemia, end-stage renal disease, cancer, or cardiac arrest, the cost of one’s healthcare is not insubstantial.

We recently have heard debate over the value of colon and breast cancer screening as it is currently being done. Many treatments for older persons with chronic illness have been questioned due to their cost and potential benefit. While I have always been against using chronological age itself as a deciding factor when considering most treatment options, I do consider physiological age, as best as it can be determined, and estimated “quality” life expectancy in my discussions with patients and their families when considering options for care. Basically, each situation must be decided, in my opinion, on a case-by-case basis by weighing all of the facts and available evidence upon which to make a cogent conclusion.

As we continue the healthcare debate and ponder the cost of providing essential medical care to our nation’s populace, however, we must face the inevitable question of “What needs to go?” While some may argue that money must be found elsewhere and not from the existing healthcare system—perhaps from reducing the military budget, increasing taxes on those individuals and/or corporations who are best able to afford to pay them, adding “pleasure taxes,” or finding some other revenue source—many believe that at least part of the cost can and should come from a re-organization of the way we currently fund Medicare and finding ways to reduce “duplication and waste” in our healthcare system. Clearly, we can benefit from such practices as negotiated prices for Medicare drug payments, as is done by the Veterans Administration with great success.

Every day, however, I see tests repeated because records were not available from “outside facilities,” unnecessary testing being done even in those individuals who decided ahead of time that regardless of what is found they prefer not to receive treatment, and treatments initiated that may prolong one’s quantity of life for some brief time without the hope of extending meaningful quality life. Additionally, medications are being given at great cost, even if they have been shown to increase one’s lifespan by only a few months on average.

Clearly, life is precious, and every day of quality life is worth preserving—don’t get me wrong—but as stated above, funds must be found from somewhere if we are to move forward with a much needed revision of our healthcare system. Those without advocates willing to present cogent arguments and fight for what they believe is justified may find their issue on the chopping block of healthcare reform. In England, for example, a woman with metastatic breast cancer that is HER-2 positive cannot be placed on the treatment combination capecitabine/lapatinib at government expense, as is an increasing practice in the United States. While research data presented in the United States in order to get these medications approved for this indication did show a statistical benefit in survival time, it is in the order of only a few months and at a cost of tens of thousands of dollars. The question remains as to what we can afford as a nation, and where and for whom do we limit treatment. Sure, someone can always pay privately for care not covered by health insurance, but few can afford medications and/or medical care that are in excess of most individuals’ annual income.

Every day decisions are made to withhold life-extending treatment based on individual considerations, but few physicians currently consider the cost of care in these deliberations. We assume that we can spend whatever we need to, and perhaps some have gone overboard at times, ordering unnecessary tests and procedures that if additional thought was given, might have been viewed as unnecessary or futile. I remember different types of discussions not so many years ago when physicians were more dependent on managed care contracts with all-inclusive fees; many physicians seemed to be more concerned over the cost of one’s care at that time since many of us were held financially accountable for our own decisions and the tests that were ordered. I have not seen any data to imply that we took poorer care of our patients because of this or had different patient outcomes.

I like to think of the medical profession as an honorable and ethical one bound to provide the very best care possible for our patients regardless of the financial consequences. That said, we are all human, and financial incentives may indeed sway one’s practice style, if even subconsciously. Without a doubt, increasing concerns over malpractice have led to unnecessary testing, and there is, in my opinion, a need to correct this situation. Perhaps it will come as well with the new healthcare reform measures.

The challenge, in my opinion, is for members of the medical profession to re-evaluate their practices, commit to understanding the “evidence” upon which treatment options should be made, and reducing waste and cost as much as possible. If we don’t lead the way in this regard and show to others that we are able to cut unnecessary cost, others will undoubtedly do it for us as we enter this new age of healthcare reform. If we do not advocate for the elderly and their specific needs, recognizing that a high percentage of one’s lifetime healthcare costs occur in the last 1-2 years of life, I fear that older persons may find their options prematurely compromised and the choice taken out of the patient’s and physician’s hands. We all have a lot to gain in this new era and should embrace the concept of healthcare for all; there is, however, a potential downside that we must guard against and continue to advocate for our patients.

Dr. Gambert is Professor of Medicine and Associate Chair for Clinical Program Development, Co-Director, Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Director, Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, and Professor of Medicine, Division of Gerontology and Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.