Future projected trends in the care of the elderly individual with cancer, and implications for nursing

Future Projected Trends in the Care of the Elderly Individual With Cancer, and Implications for Nursing Marilyn Frank-Stromborg

T

HERE CAN BE little doubt that the next few decadeswill see profound changesin health care financing and delivery. The cost and quality of health care will continue to be major national issuesinfluenced by the demographicchangesthat will occur in American society. The growing older population will play increasing roles in shaping organizations, financing, delivery mechanisms, and service provision in the health care arena, as well as in changing the emphasisin the practice of medicine. ’ Experts predict that the major health problems in the West by the year 2000 will be diseases associated with an aging population.2 These age-associateddiseases are cancer, heart disease, and central nervous system disorders. DEMOGRAPHIC CHANGES IN THE AMERICAN SOCIETY

When the American republic began, the life expectancy was 35; today it is 75 years of age. One of the leading factors in the decline in mortality across all age groups is the improved living standard and medical advancesin the prevention and treatment of infectious diseasesthat formerly were often fatal. According to the Census Bureau projections, people 65 and older, who now number about 12% of the population, will be a solid 21% of the population by the year 2030.3V4The ratio of elderly to those under 65 will probably be 1 to 5 in 1990 and 1 to 3 in 2025.5 The numbersof those 85 or over are growing three or four times as fast as any other age group. This is a population group that may require extensive support services. Furthermore, the Census Bureau predicts that there will be more than 100,000 centenariansby the turn of the century. Added to these facts has been the continuing decreasein the relative numbersof people below age 65 in the population. It must also be rememberedthat the incidence of cancer increases From Northern Illinois University, DeKalb, IL. Address reprint requests to Marilyn Frank-Stromborg, RN, EaYD.School of Nursing, Northern Illinois University, DeKalb, IL 60115. 0 1988 by Grune & Stratton, Inc. 0749-2081188/0403-0008$05.00l0

224

with age. The incidence of cancer at the age of 25 is less than one in six hundred but by the age of 70 has risen to about one in ten. Thus, with the increasing number of elderly people, the nurse can expect to see more people presenting with the diagnosis of cancer. The elderly use a disproportionate amount of physician time, medications, and hospital admissions. Specifically, individuals over age 65 account for over a third of the use of physician time, 25% of medications, and 40% of the hospital admissions.6Illness and injury causean averageof 40 days of disability for the elderly person each year, nearly twice that of the general population. Although the elderly comprise about 12% of the total population, they use about 30% of health costs.7 The number of days spent in the hospital (mean per year) is 3.0 for people in their late 60s 4.7 for people in their late 7Os,and 8.3 for people aged over 85.7 In 1980, people over the age of 65 made 165 million visits to physicians, and this number is expectedto increaseby 40% by the year 2000, when the use of short-term hospital care by the elderly will have risen by 50%.* Women live an averageof 7% years longer than men. The US CensusBureau projects that the difference in life expectancy between men and women may continue to increase until the year 2050, when rates will level off. At that point, life expectancy for women will be 81 years and for men 71.8 years, a 9.2 year difference.’ The proportion of very old women to very old men has increased throughout this century: In 1900 there were 96.3 men per 100 women aged over 75, in 1979 there were 45 men per 100 women aged over 85; and by the year 2000, there will be 39.4 men per 100 women agedover 85.9 All thesefacts have sobering consequencessince older women have fewer personal financial resourcesfor health care than men, they are much more likely to spendtime in a nursing home or to need home care services, and current health care reimbursement does not meet their needsfor financial coverage of ongoing outpatient care.’ As the numbers of elderly increase, so will health care costs. Experts write that the anticipated Seminars in Oncology Nursing, Vol4,

No 3 (August), 1988: pp 224-231

FUTURE TRENDS IN CARE OF ELDERLY WITH CANCER

growth in this group will rapidly exhaust available resources unless less expensive ways to provide health care are found. Trend: Significantly increasing numbers of the elderly in the American Society. By 2030, 21% of the population will be elderly. WHERE HEALTH CARE WILL TAKE PLACE IN THE COMING YEARS

The current approach to care of the elderly has emphasized acute care, hospital care, and longterm institutional care. This will change dramatically as the percentageof elderly increasebecause the medical conditions of the elderly are predominantly chronic, and the health care payment system will continue to limit accessto hospitals. Presently hospitals are the core institutional provider of health care in the United States,but the demandfor hospital inpatient care is declining and will continue to decline for the next 20 years. Experts predict that 10% of the nation’s hospitals will close by 1995 due to fewer admissions and shorter patients stays.lo A look at state figures dramatically illustrates the shift from inpatient to outpatient services. In California the use of hospital outpatient services was up 5% through mid-1985 compared with mid-1984, while inpatient admissions were down 6% during that sameperiod.” Nationwide, community hospital inpatient days increased by 27.5% from 1965 to 1975, but increased only 2.9% in the years between 1975 and 1982.‘* The sametype of decline in utilization of inpatient services for cancer care is seen. The National Center for Health Statistics found that the increases in the number of elderly between 1979 and 1984 did not offset declines in the average length of stay, which for somegroups declined by 26%. The decline in the total number of days of care for cancer among the elderly ranged from 3.5% among femalesto 4.4% among males. They report that in 1985 the average length of stay for malignant neoplasmsamong those agedover 65 was 9.7 days, down 1.0 day from 1984.13 While actual days spent in hospitals by the elderly have decreasedand will continue to decline, the total elderly population in need of long-term care is expected to increase to between 7.5 and 9 million by 1990. Basedon current patternsof care it is estimated that one third will require nursing home care; one third will remain in the community but require some institutional services due to dis-

225

ability; and one third will remain in the community with sufficient resources to make nursing home placement unlikely. i4 Thus by 1990, the number of elderly in nursing homes will double and the costswill increaseto an estimated$76 billion. The challenge in the coming years will be to develop community-based screening programs that assure that nursing home placements are appropriate because it is estimated that 10% to 40% of nursing home placements are inappropriate. l4 Many elderly people are in nursing homes because they require custodial care, which is defined as primarily meeting personal needs, and do not require the servicesof a professional. Presently custodial care in the community setting is not covered under Medicare part A. Black’* has identified multiple competitive forces that are moving care from the hospital to the outpatient setting. These are ambulatory-care centers, ambulatory surgery, aftercare programs, home-infusion therapy, home care programs, and the development of alternative delivery systems that will ration hospital care through preadmission screening and preventive health services. Curtiss reports that the external forces driving down the use of hospital inpatient servicesalso include competition from the increasing supply of physicians, implementation of Medicare prospective pricing and Professional Review Organizations (PROS), and the recent growth in private use-review programs.i i Another competitive force in the delivery of cancer care is the recent development of freestanding cancer centers. In 1986 there were 216 freestanding radiation therapy centers, a 50% increase since 1980.15Presently, many freestanding cancer centersoffer only radiation; however, it is anticipated that in the near future these centers will offer comprehensive, multidisciplinary, outpatient cancer care 24 hours a day, seven days a week.l5 The delivery systemsthat involve altematives to traditional fee-for-service models are preferred provider organizations, exclusive provider organizations, health maintenance organizations, independent-practice associations, and primary care networks. These alternative delivery systems are still in the infancy stage, and only time will determine the dominant system. Clearly, with the need to decreasethe federal deficit, the number of health-care reimbursement dollars available is likely to be reducedand stay reduced in the coming years.16

MARILYN

226

The coming years will bring increasing economic pressuresto keep elderly individuals in the community setting and to have them use outpatient services, rather than being admitted to the hospital, for their chronic health problems, including cancer. Elderly receiving home-based care are not only more satisfied, but live longer, and the cost of their care is substantially less. Nurses working in ambulatory and home care settings will need to have the samehighly sophisticatedacutecare skills that hospital-basednurseshave had. It will become routine for intensive treatmentsto be done in outpatient setting. l1 New technological developments are providing health care providers with the necessary equipment to provide “high tech” treatments in outpatient settings. Trend: Health care will routinely take place in ambulatory care settings and in the home. Hospital admissions will be limited to the sickest individuals and they will be dischargedas soon as possible to continue receiving their care in the home or chronic care setting. WHO WILL FINANCE HEALTH CARE IN THE COMING YEARS

The need to restructure the financing of health care service in this country becameevident in the early 1980swith the rising cost of medical care and the drain those medical expenseswere putting on the Medicare Hospital Insurance Trust fund. The annual trustees’ report on Medicare’s Hospital InsuranceTrust Fund indicates that the fund will be solvent through either 2002 or 2006. However, others feel the fund will be solvent only through 1996.l3 National health expenditures increasedalmost 1Zfold between 1960 and 1982, from $26.9 billion to $322.4 billion, or from 5.3% of the gross national product (GNP) to 10.5%.17In 1985, total expenditures for health care exceeded$400 billion, which is around 11% of the GNP,” and it is anticipated that by the year 2OflOhealth care expenses will be $1.5 trillion, representing 15% of the GNP.13 It must be pointed out that by the year 2000, 50% of all health care expenseswill be related to the care and treatment of people aged 65 and older. l9 Prior to the enactment of the 1982 Tax Equity and Fiscal Responsibility Act (TEFRA) and the Social Security Amendment passed in 1983,.the health care reimbursement system was based on

FRANK-STROMBORG

retrospectivepayment of servicesrenderedby physicians and hospitals. By the early 1980sthe government shifted from retrospective, full-cost reimbursementof the individual hospital to prospective compensationby defined medical care.2oWith the advent of the Prospective Payment System (PPS), a revolution in health care began that is embodied in the phrase “cost containment.” The trend underlying all recent developments, among both private and public payers, reflects restriction of use of health care services as well as price controls.12 Diagnostic Related Groups (DRGs) were selected as the prospective payment methodology. DRGs is a classification system that organizes patients into groups based on homogeneity of resource consumption. The major factor underlying the use of resourcesin this systemis length of stay of the patient. Patients are assigned a DRG upon discharge from the hospital, and the hospital receives the reimbursement set for that DRG. The prospective-reimbursement strategy in effect put hospitals on a budget. It provided a powerful incentive for hospitals to cut costs becauseif a patient is discharged with a decreasedlength of stay (when compared with means established through DRG data), the hospital profits. If a patient exceeds the expected length of stay or exceeds the expected costs (defined as outliers), the case is reviewed by a PRO that determines appropriateness of admission and care. The decision of the PRO determines if the hospital is reimbursed. While DRGs initially applied only to Medicare patients, it is expectedthat eventually the DRG system will directly or indirectly affect all medical and health care practices.21It is also anticipated that the prospective payment system concept will be implemented by private insurance plans within the near future. For instance, Blue Cross and Blue Shield of Kansashas implemented a statewideprospective payment system designed to provide an incentive to providers to keep their charges down.22 The elderly have more than twice the rate of hospital use than those under 65 years of age. For example, the rate of hospital admissionsof persons aged 75 and over is 5 1% higher than that of persons aged 65 to 74, and their rate of hospital days in 70% higher. l7 Thus they will be most profoundly affected in the coming years by the trend to restrict use of health care services. Since the

227

FUTURE TRENDS IN CARE OF ELDERLY WITH CANCER

advent of the prospective payment system, Medicare admissionshave declined. Admissions in fiscal year 1984 were 1.7% lower than in fiscal year 1983, in contrast to an averageannual increaseof 4.6% from 1978 to 1983. For fiscal year 1985, admissions declined another 5.6%) leaving Medicare admissions 15% below where they would have been if earlier trends in hospital admissions for the elderly had continued.23 In fact, with the reduction in the federal deficit mandated by the Gramm-Rudman-Hollings Act that took effect on March 1, 1986 there appearsto be little hope that more comprehensiveMedicare or Medicaid coverage will become available in the foreseeable future.24 The only exception to this is the pending catastrophic insurance bill that, if adopted, would be the greatestexpansion of Medicare coveragein its 22-year history. The fast paceof reimbursement developmentsand regulatory changesaffecting the delivery of health care services appearslikely to continue until spending for medical care is brought under greater control. ’ ’ The proposedgovernment budget cuts, together with the potential effects of the GrammRudman-Hollings Act, will result in more outof-pocket payment by Medicare patients as well as higher monthly premium rates. A General Accounting report (April 1987) indicates that between 1980 and 1985, the average annual out-of-pocket Medicare costsfor part A rose 49%, and the annual rate of increase for part B was 31%.l3 Thomas Nelson, coordinator of consumer affairs for the Association of Retired Persons, raises concerns about the increasing expectation that the elderly pay for their health care out of their own pocket. “The elderly patient currently pays one-third of his/her own health care bill averaging $1,500 in out-of-pocket expensesa year, or 15% of his/her fixed income. If the cost of health carecontinues to rise at the current rate, by 1995the bill will be over $7,000, over 40% of the older person’s income. ,725 Trend: Every attempt will be madeat the federal level to control and reduce health care expenditures by the elderly. This will meanthat the elderly may incur more out-of-pocket costsand pay higher monthly premiums. Access to health care will be regulated, and medical care will receive increased scrutiny to assuremedical necessity and appropriateness.

FUTURE IMPLICATIONS FOR BOTH THE ELDERLY CANCER PATIENT AND HEALTH CARE PROFESSIONALS

The changesdiscussedearlier are transforming the financing, organization, and delivery of health care in America. Many of these changesare going to have a major impact (negative and positive) on the elderly individual who has cancer. Impact of DRGs on Care of the Elderly

In 1987, Kramer and Schmalenberginterviewed over 1,000 hospital-basednurses to determine the impact of DRGs and prospective payment on the nurses’ practice.21,26They reported three major areas of impact. (1) There was increasedcost-consciousness,and nurses were actively involved with discussions of costs to patients. Regardlessof the direction the health care systemtakes, nurseswill be involved in cost containment and explaining costs of treatmentsto patients. It will be necessaryfor nursesto have a working knowledge of the economics of health care and sharethis with the consumers.This is particularly important with the elderly since they may be expectedto pay for a greaterpercentageof their health care including larger monthly Medicare premiums. (2) Nurses reported seeing sicker patients and having these patients discharged quicker and earlier. This changeputs increasedpressureon nurses to initiate teaching from the initial contact with the patient and family. This is frequently difficult because of the patient’s anxiety, acuity of illness, and/or age-relatedhearing/visual disorders that require educational messagesto be delivered at a slower pace. Becauseof the significantly reduced time for teaching, it will become necessary for hospital-based nurses to develop “linkage” programs with community and office-based nurses to assure continuity of care and patient education. Everything the elderly cancer patient needs to know cannot realistically be taught in the short amount of time allotted for hospitalization (ie, to determinethe diagnosisor for the initiation of therapy). It will be necessaryfor nurses in outpatient settings to continue the educational programs started in the inpatient setting. Mechanisms to assure continuity of care/education will need to be developed. With the increasing utilization of outpatient settings, nurse oncologists in these settings

220

will have to be involved in providing patient education and psychosocial care. In a survey by the Association of Community Cancer Centers (ACCC) only 16% of the institutions reported additional reimbursement above and beyond that for doctors’ fees.l3 Thus, there are questions about who will pay for the increasing functions and responsibilities of nurses in outpatient settings. (3) An indirect effect of DRGs is that there is increased specialization among nursesas hospitals develop their “product lines” for marketing purposes. Because of the illness acuity of admitted patients, hospitals have placed emphasis on education and certification of the nursing personnel. An example of the trend toward increasing certification of nursing staff is reported by ACCC.13 They report that 88% of the institutions in the organization have nursescertified to administer chemotherapy. The average percentage of oncology nurses who are presently certified at each hospital was 76%. Many hospitals provide programs for certification of nurses, and these range from chemotherapy programs to programs preparing nurses for the Oncology Nursing Society certification test. Another effect of increasedacuity of illness is that hospitals are moving toward all-RN staffs. Newman found that the RN complement in the Twin Cities ranged from 69% to 88% in three hospitals she studied.27 These changesall have positive implications for elderly individuals with cancer. In the coming years, they are more likely to be cared for by a highly trained nurse who is certified in someaspect of oncology nursing than were patients 10 years ago. In fact, it probably will not be uncommon for the nurse to have specializedin geriatric oncology. Spitzer and Davivier predict that by the year 2020 the geriatric nurse may be the most prevalent and widely needed resource for available health care services.l9 Becauseof the economic emphasison early discharges, the elderly cancer patient can be assured that patient education will be intensive from the earliest contact with health care professionals. The goal of the educational contact will be to promote self-care and independence.Again, the strong emphasison early initiation of teaching and discharge planning was not present 10 years ago. Catastrophic Insurance Bill

On October 27, 1987 the Senatepassedlegislation to cover the catastrophicinsurancecostsof the elderly. The House passeda similar bill in July.

MARILYN

FRANK-STROMBORG

Under the bill Medicare would cover 80% of the out-of-pocket expenses for acute care that exceeded$1,850 per year. Starting in 1990, a drug benefit would be phased in, which would cover 80% of out-of-pocket costs that exceed $600 per year. This acute care coverage would cost the elderly about $4 per month, while the drug benefit would cost about $4.50 per month.28 Successfor passage of this bill goes to the strong “gray power” that was evident at the hearing in Washington and that put pressure on Congress to pass the bi11.29As of this writing (November 1987) a conference committee is expected to reach agreement on the bill within a few weeks and then it will go to the Presidentfor signing. It is anticipated that there will not be any opposition from the President. Obviously this has very positive implications for the elderly individual with cancer in terms of covering the expensesfor Medicare-covered procedures or items that would be incurred for their cancercare. This bill should help in preventing the elderly cancer patient from having to go into voluntary impoverishment to pay for the costs of the treatment of the disease. Emphasis on Wellness, Disease Prevention, and Early Detection

Another trend that is occurring in American society today that has positive implications for the elderly is the growing emphasison health promotion, diseaseprevention, and early detection. Individuals who are now middle-aged will benefit from the present atmospherethat values a healthful lifestyle (eating right, not smoking, exercising moderately) and hopefully they will continue these health-promoting behaviors into their elderly years. Many hospitals and medical clinics are offering early detection programsto market their services and are targeting the elderly for these programs. Early detection of colorectal and breast cancersare examplesof the types of free programs that are frequently targetedto the elderly. Wellness programs are springing up all over the country, especially in the Midwest; 34% of midwestern hospitals, 32% of northwestern hospitals, and 24% of those in the West report wellness programs.” Wellness programs and early detection programs are also being instituted in nursing homes, residential centers for the elderly, and geriatric centers. There is uniform consensus among health care planners that wellness programs and preventive care will play a more important role in future

FUTURE TRENDS IN CARE OF ELDERLY WITH CANCER

health care. In fact, some experts are predicting that insurance premiums will be basedon lifestyle habits. Presently, Medicare does not pay for most preventive services including mammography screening. The reluctance of Medicare to pay for mammography may change becauseof the strong evidence documenting its clinical and long-term cost benefits. The National Cancer Institute estimates that if the percentage of older women receiving mammograms and breast exams was increased to 80%, mortality would fall by 30% among that age group.29 Early detection of other cancers (ie, colorectal, prostate, cervical) in the elderly has also been shown to be cost-effective and to increase survival.30 It is hoped that as more prospective researchis performed documenting the value of early detection of cancerin the elderly that the government will alter present policy and pay for preventive services. “Rationing” of Health Care and Limited Access to Care The restructuring of the way health care is provided to the elderly and reimbursed in this country has raised multiple concerns. These concerns are: (1) Will the changesresult in “rationing” of health care; (2) will the ultimate result be a two-tiered health care system; and (3) will there be limited access to care for the poor and the elderly?4~“‘18720~31~32~33 These concerns were raised becausethe new reimbursementsystemprevents ‘ ‘cost shifting, ’ ’ which raisesprices for paying patients to cover the costs of treating nonpaying (or financially unprofitable) patients. “When prices are fixed prospectively, charity care costs can only be shifted backward to the provider’s own bottom line, and the incentive for providing charity care is removed.“*’ The fear that is expressedcontinually in the literature is that the present reimbursement system clearly encourageshospitals to avoid patients who are systematically more costly than the DRG average. There is evidence that somephysicians are also reluctant to take medicare patients into their practices for the samereasons. Iezzoni writes, “persons with multiorgan system disease or chronic disabilities may form the systematically expensive group to be avoided. Thus, large numbers of elderly may have trouble gaining accessto care.“31 This fear has come to fruition in some parts of this country and has necessitated legislation prohibiting hospitals from “dumping” nonprofitable patients. While there are laws pro-

hibiting “dumping” of patients, it’s difficult to police hospitals or monitor them to determine how widespreadthe practice is or if it continues to occur. There is also the concern that, to keep costs down, patients will be discharged “quicker and sicker” to environments ill-prepared to take care of them. Kramer and Schmalenberg’s survey of practicing hospital-basednurseshas shown that patients are being dischargedearlier than would have previously been tolerated or before patients are capable of self-care.21*26The posthospitalization support that thesepatients should have at home (ie, family support, after-careprograms, home nursing care, etc) may not be available or financially possible. Nutter makes the point that “implicit in these trends involving cost-containment strategies and for-profit health care is the rationing of care on the basis of ability to pay and, in some cases, availability of services.“24 There is considerable skepticism concerning whether society can effectively control its health care cost without rationing health services. It is envisioned that rationing will occur by virtue of the fact services will be available only if the individual can pay for it. Fomi comparedthe health care delivery system of Sweden and Finland with that found in the United Statesand made the observation that much of the health care delivered in the Scandinavian countries was by nurses.34She also observed that the Swedish and Finnish nurses were not educated at the high level of nurse practitioners in America, but they are utilized extensively in the delivery of health services. In both of these countries nurses are recognized as an important resource in the health care delivery systems. Fomi makes an eloquent plea that if nurses in this country were utilized in a similar manner, health care could be madeboth more accessibleto large segmentsof the population and be more cost effective. Thus fears such as rationing of health care and limited access do not have to be acceptedas the inevitable result of cost-containmentof health care costs. Sheurges American nurses to gear their efforts and energy toward a “restructuring of the health care delivery system, through changesin health policy and legislation, to incorporate nursing care as a significant component. This can be accomplished in several ways: (1) by political lobbying, on an individual basis and through the professional organizations, at local, state, and national levels; (2) by working through exisiting consumer groups/organizations such as the Gray Panthers and the American As-

230

MARILYN

sociation of Retired Persons;and (3) through media exposuresof radio, television, and the popular press.“34 Unless nurses are willing to become involved politically and professionally at the local, state, and national levels, the elderly cancer patient may encounter the difficulties in gaining access to health care that many are predicting. Nurses must actively work to pursuade the state and federal governments: (1) to fund preventive services that will foster early detection of cancer in the elderly and ultimately reduce morbidity and mortality, and (2) to develop and fund cost-effective “linkage” programs that are community-based, nurse-run, and designed to assist the elderly cancer patient at all phasesof the illness trajectory. These linkage programs would conduct geriatric assessmentsand coordinate the services neededto help the elderly individual remain in the community setting and to

FRANK-STROMBORG

avoid costly acute care or long-term care institutions. They would also assure continuity of care between acute care institutions, ambulatory care settings, and the home. Recentresearchdocuments that comprehensivegeriatric assessmentshelp the frail elderly live longer and avoid costly medical care. “The comprehensive assessmentsare multidisciplinary evaluations in which a person’s resourcesare cataloged, the need for services is assessed,and a coordinated care plan is developedto focus interventions on the person’s problems and disabilities. “35 In these changing economic times with quickly shifting government regulations, it is essential that nurses are proactive in assuming the role of advocate for the elderly cancer patient. Nurses must be in the forefront, proposing programs for the elderly cancer patient that are responsiveto their needs, cost-effective, and of high quality.

REFERENCES 1. Day D: Aging reconsidered:A new look at refining senior’s health care. Gncol Times 9:16,20,25, 1987 2. Wollard K: Medical advances.Oncol Times 9:2,15, 1987 3. Northrup B: Gray matters. Wall Street Joumal:33D-34D, April 24, 1987 4. Goldsmith J: The US health care systemin the Year 2000. JAMA 256:3371-3375, 1986 5. Waldman HB: Knowing more about the elderly can help if we want to provide needed services. Gerontology 4:83-85, 1985 6. Fink A, Siu A, Brook R, et al: Assuring the quality of health care for older persons. An experts panel’s priorities. JAMA 258:1905-1908, 1987 7. Gambert S: Geriatric medicine-A demographic imperative. Wisconsin Med J 81:17-18, 1982 8. Institute of Medicine: Academic geriatrics for the Year 2000~Special Report. N Engl J Med 316:1425-1428, 1987 9. Lewis M: Older women and health: An overview. Women Health lO:l-16, 1985 10. Anonymous: Health in 1995: More expensive. Cope 2:14, 1987 11. Curtiss F: Recent developments in organizing and financing health-careservices. Am J Hosp Pharm 43:2436-2444, 1986 12. Black B: Competitive alternatives to hospital inpatient care. Am J Hosp Pharm 42:545-553, 1985 13. Baum H: Oncology reimbursement review. J Cancer Program Manage 2:S-4, 1987 14. Culpepper L, Murphy J, Fretwell M: Biology, primary care, family, and community. A basis for rational geriatric care. Clin Geriatr Med 2:37-51, 1986 15. Cahill E: Freestanding cancer centers: The changing

courseof cancercare delivery. J CancerProgram Manage 2: ll20, 1987 16. Council on Long-Range Planning and Development: Health care in transition. Consequencesfor young physicians. JAMA 256:3384-3390, 1986 17. Scitovsky AA, Capron AM: Medical care at the end of life: The interaction of economics and ethics. Ann Rev Public Health 7~59-75,1986 18. Ginzberg E: The restructuring of U.S. health care. Inquiry 221272-281,1985 19. Spitzer R, Davivier M: Nursing in the 1990s:Expanding opportunities. Nurs Adm Q 11:55-61, 1987 20. Reinhardt U: Rationing the health-care surplus: An American tragedy. Nurs Econ 4:101-108, 1986 21. Kramer M, Schmalenberg C: Magnet hospitals talk about the impact of DRGs on nursing c-Part I. Nurs Manage 18:38-42, 1987 22. Dauner M: An insurance executive looks at changing patterns of health care. Hosp Community Psychiatry 36:160164, 1985 23. Ginsburg P, Hackbarth G: Alternative delivery systems and medicare. Health Aff 5:6-22, 1986 24. Nutter D: Access to care and the evolution of corporate, for-profit medicine. N Engl J Med 311:917-919, 1984 25. Porter S: A fork in the road of medical care. Is a twotiered health care systemjust aroundthe bend? Ohio State Med J July:511-525, 1984 26. Kramer M, Schmalenberg C: Magnet hospitals talk about the impact of DRGs on nursing c-Part II. Nurs Manage 18:33-40, 1987 27. Newman M, Autio S: Nursing in a Prospective Payment System Health Care Environment. Minneapolis, University of Minnesota, 1986

FUTURE

TRENDS

IN CARE OF ELDERLY WITH CANCER

28. American Nurses’ Association, Washington Office: Capital Update 5:4, November 6, 1987 29. Anonymous: Legislative Network for Nurses 4:4, November 23, 1987 30. Albert M: Health screening to promote health for the elderly. Nurse Pratt 12:42-58, 1987 3 1. Iezzoni L: Changein the health care system. The search for proof. J Am Geriatr Sot 34:615-617, 1986

231

32. Edwards K: Ohio plans for the care of its elderly. Ohio State Med J March:195-197, 1984 33. Yasko J, Fleck A: Prospective payment (DRGs): What will be the impact on cancercare?Oncol Nurs Forum 11:63-72, 1984 34. Fomi P: Health care delivery in Sweden and Finland: A challenge to the American system.J Prof Nurs 2:234-245, 1986 35. Anonymous: Frail elderly live longer with complete assessment.Medical World News 35:November 23, 1987