Clinical Geriatrics

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.