The council's report, “Taking Care: Ethical Caregiving in Our Aging Society,” can be found online at www.bioethics.gov/reports/taking_care/index.html
WASHINGTON — The issues of aging, dementia, and long-term care merit formation of a presidential commission, the President's Council on Bioethics suggests in a new report.
At its recent meeting in Washington, the commission heard from Greg Sachs, M.D., chief of the section of geriatrics at the University of Chicago, who said that when it came to caring for dementia patients, he was “less worried about the advancing number of people and smaller numbers of caregivers … and much more worried about the propensity to overtreat, to not provide good end-of-life care, and in fact, to have a health care system that is particularly ill-suited for the ongoing care of people with dementia.”
Current financial incentives don't encourage the idea of letting dementia patients die peacefully at a nursing home, Dr. Sachs said. “When the [nursing home] patient has pneumonia and is getting close to dying, the nursing home has to provide more care … but they are not reimbursed more. Depending on where they are and if the patient is on Medicaid, if they send the patient to the hospital they can actually be paid a 'bed-hold,' and they are actually making money while the patient is in the hospital, rather than losing money from having to provide additional care.”
In addition, the physician, instead of being paid at a lower rate and making less frequent visits, “hospitalizes the patient and makes more money by seeing the patient on a daily basis and gets reimbursed at a higher rate,” he continued. And the hospital makes money because pneumonia is a disease for which the payment often exceeds the cost of care.
“All the financial incentives are aligned for this patient to be transferred to the hospital rather than being cared for in the nursing home and being allowed to die peacefully,” he said.
Robert Friedlander, Ph.D., director of the Center for an Aging Society at Georgetown University, Washington, told the council that although most of the caregiving for elderly patients is provided at home—often by family members—three-quarters of the money spent on caregiving is spent at institutions. This is partly because institutional long-term care is a mandated benefit under Medicaid, whereas home- and community-based care is not.
But “there have been tremendous efforts on the part of states to move care out of the nursing home,” especially since states think care is cheaper outside of institutions, he said. “This rebalancing has meant that in the period from 1991 to 2001, the expenditures in home- and community-based care in Medicaid have more than tripled, from $6.2 billion to $22.2 billion.”
There has been movement toward changing the financing of long-term care. “The past 6–8 years, most of the focus has been on tax credits for caregivers and more public incentives for the purchase of long-term care insurance,” Dr. Friedlander explained.
More fundamental changes need to be made to the long-term care financing system to ease the burden on caregivers than are currently in place, Dr. Friedlander said.
Further, things will only get worse as baby boomers live longer, and there are fewer children to support and care for them. “I would call these the best of times. I think when we get to the real crisis, these are going to look like the good old days.”
Peter Rabins, M.D., codirector of geriatric psychiatry and neuropsychiatry at Hopkins, said there was another element of the long-term care system that was worth considering. “Probably about 1 million or so people now live in assisted living, and studies just completed by [myself and colleagues] show that, just as in nursing homes, about two-thirds of individuals in assisted living have dementia,” he said.
As a result, “all the relatively mild dementia cases are in assisted living and what has happened in nursing homes is that they now treat the very advanced patients,” he said. “So nursing homes have changed very dramatically. I think that's very important to keep in mind.”
Leon Kass, M.D., American Enterprise Institute, retired as council chair at the September meeting.