Economic issues in the care of the elderly cancer patient

Economic

Issues in the Care of the Elderly

Cancer Patient

Arlene E. Fleck

T

ODAY’S nursing, medical, and lay literature regarding the elderly universally addresses the monumental concern about the health of our graying America. Over the next 50 years, the number of elderly individuals in the U.S. will double,’ and one out of every five will be 65 years or older.2 With this group emerging as the most rapidly expanding segment of our population, the health care of these individuals has becomea major national concern. During the last several years dramatic changes have occurred in policies affecting health care for the elderly. Programs of health care and benefits have been developed and/or expanded at significant expenditure of federal monies. When a large proportion of public funds is allocated to one segment of the population, a “red flag” is waved; various sectorsof society then attempt to influence or implement health policies that favor their interests. When the issue is health care these groups include (1) the consumer, who is concernedabout the rising cost of deductibles, premiums, and outof-pocket payments; (2) the third-party payers including Medicare, Medicaid, Blue Cross, commercial insurances, and health maintenance organizations (HMOs) who are concerned about increasing numbers and costs of reimbursable charges; (3) the legislators, who are trying to control the health expenditure of the Gross National Product (GNP); (4) the health care providers, who want to stay in businessbut at the sametime maintain a competitive quality of patient care; and (5) the big businesseswho want to control their expenditures of health insurance premiums.3 As the largest group of health care providers, nurses, too, face the dual challenge of providing care that is competitive, cost effective, and yet of a quality compatible with our professional standards. Care for the elderly is no exception. With 50% of all cancersoccurring after age65, the practice of oncology nursing will be predominantly involved with the elderly population4 As the greater proportion of our population approachesold age, those nurses specializing in oncology may need to subspecializeinto geriatric oncology. Just as nursing interventions differ depending on the patient’s treatment modality and stage of illness, nursing Seminars

in Oncology

Nursing, Vol 4, No 3 (August), 1999: pp 217-223

practice will need to focus on distinct age categories. The obvious parallel is the current subspecialty of pediatric oncology. In developing effective strategies for patient care, the nurses must consider the impact of the individual’s formative years. Piaget labels these years the formal operation per&L5 It begins in adolescenceand spansthe agesof 12 to 18 years. During this time, youths1becomecapableof thinking, conceptualizing, and hypothesizing.5 These years are significant in developing philosophies on life and/or cultural expectations.To emphasizethis concept, consider the following: In 1987 you meet a patient who is 63 years of age. What historical event, life crisis, or medical discovery occurred during the patient’s formative years, or in the 193Os?Answer: At that time the Great Depression occurred. Individuals were not encouragedto ask questions regarding health care symptoms. Physicians were seen as rather saintly individuals and the diagnosis of cancer was fatal. (Keep in mind that chemotherapywas only introduced as a treatment modality in the late 1940s.) Therefore, in providing care for individuals 60 or older who are diagnosed with cancer, we must be cognizant of their perceptions of cancer as a hopelessdisease,of the health care systemas mysterious and frightening, and of money matters being a serious and worrisome issue. McCaffrey6 reported that misconceptions about cancer increase with subsequentdecadesof life. To intervene effectively and efficiently, oncology nurses must dispel the myths or misconceptions about cancer, emphasizingthat today’s medical advancementhas improved the cure rate of cancer to 50%.’ Nurses must also encouragepatient/families to ask questions about their illness, serving as a patient advocate when necessary. Finally, and perhaps most importantly, nurses must feel comfortable in allowing patient and family to discusstheir financial From the University of Pittsburgh and the Pittsburgh Cancer Institute, Pittsburgh. Address reprint requests to Arlene E. Fleck, RN, MNEd, 2015 Be&wood Dr. Pittsburgh, PA 15243. 0 1988 by Grune & Stratton. Inc. 0749-2081l88/0403-0007$05.00/0

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ARLENE E. FLECK

frustrations and to provide appropriate teaching and counseling. In the past, when a patient or family raised the issue of money, nursesreferred them to the Social Services Department. In today’s health care settings, time and limited resourcesmay well prohibit a social service consult, especially in an ambulatory clinic or physician office setting. However, when the patient and family are burdened with financial worries, the compliance with treatment, including medication, and the follow-through for health maintenance programs are likely to be neglected. For example, a common treatment for elderly women with breast cancer is tamoxifen, the cost of which is one dollar per pill. Patients may not comply with this therapy becauseof the high cost, while concurrently compromising their treatment goals. When the nurse identifies and acceptsthe priorities identified by the patient and family, the patient is more confident regarding his or her nursing care. With individuals who are 65 years and older, priorities are likely to focus on a decreasedincome due to retirement, coupled with an increasedconcern for financial security. Nurses must be proactive in addressingthis issue. Increased awareness and education concerning economics and financial issuesand the ability to efficiently refer the patient/ family for assistance will become an essential component of nursing’s repertoire. If we, as nurses, fail to recognize that these issuesare relevant to our practice, while the population we service identifies them as a priorities, we will soon become inadequate in meeting their health care needs. An inability to incorporate these concerns into the plan of care and to devise appropriate interventions will significantly decrease nursing’s pivotal role and perceived value within the health care team. An appreciation for the economic situation in health care can be enhancedby an understanding of the history and development of our current health care practices. AN HISTORICAL OVERVIEW

The past 50 years have been characterizedby a major concern for avoiding economic disastersfor the aged family, a fear initiated by the Great Depression of the 1930s. As a result, important economic and health care policies were developed. In 1935 the Social Security Act (SSA) was passed, the purpose of which was to provide an income

maintenance for the elderly individual. The first two programs under this act, Title I Old Age Assistanceand Title II Old Age and Survivors Insurance, evolved s10wly.~These programs were successful in decreasingthe elderly’s dependenceon a public welfare program. By the 1950s for the first time more of the elderly were receiving Social Security benefits than were receiving Public Assistance (public welfare program).’ The following is a list and description of current programs that were developed from the Social Security Act to meet the needs of the elderly. (Any figures or descriptive information are dated to 1987 unless otherwise indicated. This may change frequently, so check with a Social Security representative for the most accurate information; these figures are included primarily to give the reader a senseof reference.) Social Security This national program provides a monthly income for an elderly individual when his/her earnings are eliminated or reduced becauseof retirement, disability, or death.’ Social Security benefits are funded by the current working force and are intended to supplement savings, pensions, and investments. Monthly benefits include: (1) retirement check when you stop working as early as age 62, (2) disability checks for a worker who becomesseverely disabled before age 65, and (3) survivor’s checks for the worker’s family, if the worker dies. Before an individual can receive monthly checks, a credit must be established for a certain amount of work under the Social Security System. The exact amount of the Social Security check is related to work credit (ie, an individual’s earnings over a period of years) and date of birth.’ At the present time, retirement at age 65 ensures maximum payment. One can retire as early as age 62; however, the amount of the retirement check will be reducedpermanently, depending on the number of months one receives checksbefore reaching age 65. Currently, there is discussion about raising the retirement ageto 67. lo If an individual qualifies for more than one check (ie, own work and spouse’s work), the check will be issuedin an amount equal to the larger of the two figures.’ SupplementalSecurity income (SSI) This federal program pays a monthly rate to the elderly who are poor, ie, whose assetsdo not ex-

ECONOMICS AND THE ELDERLY CANCER PATIENT

teed $1,800. l1 Age and limited income are not the only determining factors for this benefit. This program also pays benefits to the disabled and blind who have limited income and assets. Income is defined as cash or checks received or items received in place of cash (ie, food or shelter). Assets include things owned (real estate, securities, stocks). In 1987 the basic federal SSI payment for an eligible single adult is $340 a month.” Not everyone gets the basic federal amount. Some get less becauseof their income, and others get more becausethe state they live in supplementsthe federal payment.’ ’ Individuals eligible for SSI may also be eligible for social services (housekeeping help, meal assistance,transportation) provided by the individual state or county. In 1985, fewer than 2% of older Americans were totally dependenton ssI.8 The number of elderly individuals who are poverty-stricken has dropped with the enactment of Social Security. In 1936, 75% were in poverty, and in 1987, 15% are in poverty, that is income and/or assets not exceeding $1,800.8 However, this 15% is still a figure for national concern. Medicarelkledicaid

In 1965 the SSA was expanded to include Medicare (Title XVIII) and Medicaid (Title XIX). These amendmentswere developed in responseto the elderly’s lack of resourceswith which to purchase medical care.8 Medicare is a federal health insurance program for people 65 or older. People with permanentkidney failure and other disabilities are also eligible. l2 Medicare is divided into two parts, part A for hospital costs and part B for medical costs. Part A helps pay for inpatient hospital care including certain follow-up care. Part B helps pay for doctor service, medical service, and other items. Coverage is free for part A but is related to the eligibility for Social Security or federal work credits. While this is not a requirement for part B, this coverage has a monthly charge of $24.80.12 Part A covers four areas: inpatient hospital, skilled nursing facility, home health, and hospice. Inpatient hospital care benefits are paid in 90-day periods. The period startsthe first time a Medicare patient is admitted and ends when the patient has been out of a hospital or nursing home for 60 days in a row. However, patients pay the first $520 of the hospital bill. ‘* Coveragechangesafter the first 60 days, and recipients may be required to pay an

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additional charge for services. This inpatient care is reimbursableto the hospital through the prospective payment system. This system reimburses a fixed payment that is determined by the severity of the patient’s problems using the diagnosis related groups (DRGs). Skilled nursing care (SNC) is also covered for up to 100 days as long as the admission follows a hospital discharge. Skilled nursing care is defined as care that can be performed only by or under supervision of licensed nursing personnel.13It is interesting to note that in spite of the growing geriatric population, only 2% (1981) of all Medicare spending was for this benefit.14 Home Health Services are available if an individual is confined to his or her home. By definition, a patient is considered homebound if it is a considerable taxing effort for him or her to leave home-l5 If this definition is met, the cost of home health visits from a participating home health agency can be fully approved. However, the most significant dilemma is that although more patients are being followed at home, Medicare is not paying for their care because they do not meet the definition of homebound. Between 1983 and 1986 Medicare tripled its denial rate for home health visits. l5 Hospice care can be provided for a terminally ill patient only when the care is provided by a Medicare-approved hospice. Hospice services include doctor’s and nurse’s services, medical appliances,outpatient drugs for pain relief, home health aides, homemaker services, medical social services counseling, and short-term inpatient care including respite care.l4 A patient who has Medical coverage (Part B) pays the first $75 in doctors’ bills once a year. Once this “deductible” has been paid by the patient, Medicare will pay 80% of what they believe to be reasonablecostsfor doctor’s services.l4 Doctors’ services include surgical services, diagnostic tests, x-rays, medical supplies furnished by a doctor’s office, services of the office nurse, and drug administration in the office. State-Originated Services

Many special programs are initiated by individual statesto meet the needs of the elderly. These programs, which vary from state to state, include subsidies for heating, transportation, and low-cost meals.l6 Many are supported through lottery programs. The need for local and state involvement

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will continue to grow as federal monies shrink and individuals from the “grass roots” of society make demands. NURSES AS PATIENT ADVOCATES

Nurses should be familiar with several other geriatric/economic issues. Consumersof health care, specifically the aged, need assistanceto pursue options for health care benefits. A few examples are discussed. The Appeal Processi

Medicare patients may challenge decisions about their hospital care, such as being denied admission or discharged early. The Federal Health Care Financing Administration (HCFA) has hired a Peer Review Organization (PRO) for each state. The function of the PRO is to review Medicare payments to hospitals and handle patient appeals. It is important to realize that Medicare does not acutally restrict hospital stays; however, hospitals can make individuals pay out of their own pocket for any further care once the patient has reached the Medicare designated limit and has been discharged by the hospital. If patients feel discharge decisions are inappropriate, they can appeal to the state’s PRO. Nurses should be knowledgeable about this processin the statewhere they practice. Supplemental Insurance

These insurance programs offer coverage for services not covered by Medicare. This supplement is commonly referred to as Medigap. About 80% of the nation’s 30 million Medicare recipients have some form of Medigap, according to insurance industry figures.17 This representsnearly $6 billion per year spent on supplemental Medicare coverage.l7 Choosing a supplemental insurance can be very confusing. Although many elderly patients fear depletion of their finances, they are misinformed about the gaps in health benefits that are not covered by Medicare. They mistakenly believe that everything will be covered by their health care benefits. Nurses can suggestthat individuals making such a purchase should consult their state insurancedepartment for assistance. American Association of Retired Persons (AARP)

The AARP is a national organization that is growing in numbers; it presently has a membership of approximately 25 million individuals. They are

E. FLECK

very active in lobbying for legislative changes to meet the needsof the elderly. Nurses could easily serve as a resource for educating this membership in mattersrelated to health care. When the elderly and their families are educatedto voice their opinions asconsumers,the combined form of advocacy by families and nurses is more readily heard by policy makers. PRESENT TRENDS AND PROPOSED LEGISLATION

For different periods of time, there are specific needsfor the geriatric population. In the late 1980s severaldirections are being discussed.A brief synopsis of several of these are presented. Health Maintenance Organizations

HMOs provide health care through group medical practices (doctors, clinics, hospital) who work for set fees and share in the profit and loss of the individual HMO. The services provided by HMOs have an estimated 5% savings compared with the traditional approaches.‘* The federal government has a marketing campaign to encouragethe elderly to transfer their Medicare benefits from the traditional approachof independentphysicians and hospitals to this new trend. Although many Medicare recipients might be attracted to HMOs because there is less paperwork, and deductibles and copaymentsfor doctors and hospitals are eliminated, the elderly must be aware that a monthly premium must be paid to the HMO. Also, HMOs represent new health care systemsand still have implementation problems. Respite Care

Respite care is a program for the caregiver of impaired elderly patients rather than for the elderly patient, l9 It is individually tailored and has a oneto-one ratio of patient to staff member in the patient’s home or an overnight institution. Respite care is designed to provide relief to the caregiver and possibly avoid institutionalization for the elderly patient. The most frequently mentioned problem for caregivers is their experience of confinement and inability to participate in out-of-home activities.*’ Another concept similar to respite care is adult day care; it also involves the provision of personal care and services. However, in adult day care elderly individuals are transported to the center where many other individuals are receiving the

ECONOMICS AN0 THE ELDERLY CANCER PATIENT

sameservices, and it is for a specified time of day on a regular basis. With today’s two-career families, caregiving is a tremendous burden.*l Many respite programs are being funded through foundations. Evaluations have shown that respite services for clients, family, and community appearto be indispensable.** Long-Term Care Insurance Coveragefor long-term care (LTC) is extremely limited and is another option for consideration. The type of servicesdependson the individual policy. Skilled nursing care is the predominant areaof coverage but intermediate nursing care and custodial care may also be covered. Medicare has little reimbursement for long-term care, which has resulted in many elderly individuals spending their life savings for this care. Of the $27.3 billion spent in 1982 on nursing home care only 1.6% came from insurance.23Long-term care insurance policies are expensive and premiums are determined by age. Although most policies are available in only a few statesand are sold by a relatively small number of companies, their sales are rapidly increasing. In 1983, 16 companiesoffered such policies; by 1986, this number had increasedto 3 1.24 The insurance companies have the right to raise premiums from year to year and reservethe right to exclude people whom they consider to be high risk. Conditions that may exclude people are from a broad range of diseasecategories,including cancer, acquired immune deficiency syndrome (AIDS), Parkinson’s disease,Alzheimer’s disease, and epilepsy. In 1981, the Consolidated Omnibus Budget Reconciliation Act (COBRA) created a special task force to study LTC insurance. Catastrophic Illness Legislation In February 1987, President Reagan proposed broadening Medicare to cover hospital stays that exceed 90 days and developing a plan to protect individuals from losing their life savings if struck with a catastrophic illness.25This proposal has the potential to be one of the most significant changes since Medicare’s inception. The extra costsfor implementing this program will be generatedthrough increasing fees for health care among the middleand upper-income retirees. Congress is hearing significant protest from the large percentageof individuals who are already paying for supplemental insurance. Other controversial issuesabout this bill

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include coverage of prescription drugs, coverage of indigent elderly, inclusion of mental health benefits, and coverageof annual colorectal exams and mammogramsevery 3 years. ECONOMIC PROJECTIONS

When planning our future as oncology nurses we must ask the question, “How will the future generation of elderly behave, and what will be their priorities?” In January of 2011, when the first baby-boomer turns 65, a new era of health care will be established. The baby-boom generation, those people born between 1946 and 1964, is now one third of the American population.26 Although the formative years for this generation cover a diverse range of time, an important philosophy of life has been “live for today. ” Because of their great number, (78 million baby-boomers concentratedin a 19-year age s~an)*~this group is a very powerful sector of the toal population. The baby-boom generation has pursued a common pathway in life: go to college, start a career, buy a house, get married, have children. This consistent pattern of events has provided the baby-boomers great financial gain and subsequenteconomic influence. In Russel’s article, entitled “Business and the Baby Boom,“26 several rules of life for the baby-boomer generation were discussed: Rule 1. Two incomes are needed to support a middle class life style. Issuesof increasing importance include job wages, houses, schools, taxes, and investments. Two thirds of thesecouples have two incomes. Rule 2. Free time is at a premium. Only 16 hours a week are spenton leisure. Conveniencesin life and easy access to them is important. Any device that savestime is readily accepted,such as a microwave. Rule 3. Baby boomers want to spend more free time at home. The home is regarded as the hub of family activity. Toffler, in his book The Third Wave,27describesthis transformation as the ‘ ‘electronic cottage.” Rule 4. Baby boomers want to have immediate gratification and fun. Television and easy credit have been popular themes. So, in about 3 decades,when the baby boomers begin to retire, what can we predict about their behavior, health care needs, and specifically, their cancer care needs?Several themes evolve: (1) They are likely to be concerned,about their

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financial status. Accustomed to the buying power of two incomes, their pension may no longer be adequate to sustain their usual life style (rule no. 1). (2) Cancer will be viewed as a chronic illness with improved survival rates. Potentially beneficial treatments, even if costly, will be desirable alternatives (ie, clinical trials). (3) They will expect to receive the best. (4) More leisure time may be a difficult psychological adjustment;loneliness may continue to be a dominant sociological problem (rule no. 2). (5) Health care services in the home will be more predominant, and self care will be not only a focus for the health care providers, but an expectation of the patient (rules 3 and 4). (6) The emphasis on cancer prevention experienced throughout their lifetime will continue. Participating in cancer screening programs will be more widely accepted.Thus, health care agencies will not have to invest money in marketing the idea of cancer screening; rather, the move will be directed toward improving the technology and efficiency of screening programs. (7) Finally, it will be hard to keep the generation of elderly baby-boomers interested in health care practices if they are not marketed as efficient, creative, accessible, and effective. This generation will be quick learners, self-paced, and very accustomed to learning new things by demonstration(ie , video, TV). The drudgery of step-by-step procedures will be obsolete(rule no. 4). Developmentof home videos in a format that is entertaining will be the focus for education. This generation of baby boomers will also experience a new phenomenon. By the year 2030, it is estimated that, for the first time, 21% of all Americans will be over 65 and nearly one seventh of these senior citizens will be over 85.28 As the concentrations of this elderly population increase, numbers of individuals born in the 1970swill decline, resulting in decreasing numbers of those aged 30 to 50. Thus, the elderly population will become powerful due to sheer numbers. Today, many individuals over the age of 85 are receiving care in nursing homes, at an average cost of $18,000 a year,28 often resulting in financial exhaustion. It is unlikely, however, that babyboomers will tolerate this same burden. It is also estimated that there will be fewer numbers of the young to support the expansive numbers of the elderly in our society.”

ARLENE

E. FLECK

A lifelong pattern of successamong this group in achieving their goals and desires will spur the development of new approachesto caring for the elderly. An additional advantagein this regard is that the government will largely comprise members of the baby-boomer generation. Government officials will, therefore, have the insight and the motivation to ensure financial security through institution of health care policies and regulations, and program planning reflective of the babyboomer’s philosophy of life. In an article, “How Secureis Your Social Security?” Gayer describes how Congress has made Social Security sound, safe, and solvent for the next 75 years.29 CONCLUSION

It is evident that an awarenessof the economic issuesfacing the elderly must be a major focus of oncology nursing practice. It is equally important to recognize that the elderly are not a homogeneousgroup, nor do their health care needsremain constant over time. Rather, they are an evolving population of individuals whose needs are reflective of their social and cultural development. As nursesbecomemore expert in the care of geriatric patients as a subspecialty of oncology, we must consider the impact of future population trends. When the baby-boomer generation reachesage 65, the number of persons in this age category will be at an all-time high. Interventions that are appropriate in caring for today’s elderly will be obsolete within a short period of time. Thus, nurses can no longer be comfortable knowing that today’s care needsare being met. Nurses must become proactive in developing strategiesto addressthe unique needsand expectationswhich will be evident in the aging baby-boomer generation. The major emphasis of health care planning will be the development of self-care resources and patient/family teaching materials that are consistent with the babyboomer’s higher level of education. As nursesand consumersbecomemore economically aware, the needfor a financial specialist may becomeapparent.The availability of such a person as a consultant and resourceto the health care team and to the patient may significantly enhance the quality of care offered as well as reduce the mystique associatedwith health care reimbursement. ACKNOWLEDGMENT The author would like to express her thanks to her friend and colleague, Liida Dudjak, RN, MSN, OCN, for her support in this endeavor.

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14. Brody SJ, Persily NA: Hospitals and the Aged: The New Old Market. Rockville, MD, Aspen, 1984 15. Flaherty MP, FraseJ: Promisesmade, promisesbroken. The Pittsburgh Press 1987, April 1, (Special Report, six-part series) 16. Flaherty MP, FraseJ: Promisesmade, promises broken. The Pittsburgh Press 1987, March 31, (Special Report, six-part series) 17. Flaherty MP, FraseJ: Promisesmade, promises broken. The Pittsburgh Press 1987, April 2, (Special Report, six-part series) 18. Flaberty MP, FraseJ: Promisesmade, promisesbroken. The Pittsburgh Press 1987, April 3, (Special Report, six-part series) 19. JaegerBJ (ed): Graying America and our health system. 1985National Forum on Hospital and Health Affairs. Durham, NC, Duke University, Department of Health Administration 20. Scharlach A, Frenzel C: An evaluation of institutionbasedrespite care. Gerontologist 26:77-81, 1986 21. Doty P: Family care of the elderly: The role of public policy. Milbauk Q 64:34-75, 1986 22. Miller DB, Gulle N, McCue F: The realities of respite for families, clients and sponsors. Practice Concepts 26:467470, 1986 23. Floyd 3: In searchof financing for a long-term care plan. Gerontologist 26:14-16, 1986 24. Wiener JM, Ehrenworth DA, SpenceDA: Private longterm care insurance: Cost, coverage, and restrictions. Gerontologist 27:487-493, 1987 25. Griffith H: Capitol Commentary. Nurs Bcon 5:188-191, 1987 26. RussellC: Businessand the baby boom. Am Way 20:1418, 1987 27. Toffler A: The Third Wave. Toronto, Bantam, 1980 28. Gelman D: Who’s taking care of our parents? Newsweek:61-70, 1985, May 6 29. Gauzer B: How secure is your social security? Parade Magazine:C6, 1987, October 18