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Acute Hospital Care of the El(lerly: System Resources and Constraints L. Gregory Pawison T would like to discuss six issues relating to our attempts to understand, ~ rationalize, and control Me use of technology in the care of older persons in the United States. Three of them are observations or interpreta- tions and three are suggested steps toward better management of the problem. I. In considering our older persons, it is impossible and undesir- able to separate acute care use of technology from considera- tion of chronic illness. 2. The issues of medical-care technology use in older persons are not fundamentally different in most respects from that in our population in general. Specifically, remaining life expectancy rawer Wan chronological age should be a criteria for consid- eration of technology use. 3. The implications of our tendency to focus on health care solely as a means of prolonging the quantity of life rather than the quality of life and to apply aU technologies of any possible benefit to ah heath care situations. 4. The need for basic data concerning the efficacy and cost- effectiveness of technologies, especially as they are applied to older persons. 5. The desirability of better regulation and assessment of technol- ogy, especially in the dissemination stage. 6. The need for a reimbursement and financing system for health care that rewards effective and efficient use of health care of older persons.

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ACME HOSPITAL CARE: SYSTEM RESOURCES AND CONSTRAINTS 119 Given our tight time constraints, I win only be able to highlight a few major aspects of each of these points. For those interested in a much more in-depth discussion, ~ would recommend We extensive studies by the Office of Technology Assessment (OTA) (1,2~31. SEPARATION OF ACUTE AND CHRONIC ILLNESS While it is necessary for purposes of a conference such as this one to group and categorize various discussions, there is the danger that those divisions win be interpreted as fixed. One of our major difficulties In understanding the benefits and limits of health technologies applied to older persons is our tendency to view one part of the system at a time. We use technologies in the acute care setting and assumebecause He per- son leaves the hospital alive that the application has been successful. Likewise, we attempt to constrain the system at one point, such as the imposition of the Medicare prospective payment system (PPS) for hospi- tal care, and are surprised Cat costs and utilization increase more rapidly at another point (in Medicare's case, outpatient hospital use). While, as Garrison and Wilensky have noted (4), PPS has introduced some specific problems for the hospital sector in technology use, it is a clinical fact that older patients have few episodes of isolated acute illness that have no impact on resources outside the hospital. Most diseases, even cancer and heart disease, are chronic illnesses, especially given our increasing ability to change the natural course of disease. We are just beginning to recog- nize that we must focus on the course of illness, including acute exacerba- tions, functional abilities, and (as I win discuss in a moment) dying, if we are to learn the appropriate use of technology in our older population. AGE VERSUS LIFE EXPECTANCY There is an increasing frequency, especially in the lay press to pose the questions as to whether the use of a given health technology by the elderly is appropriate or cost-effective. By so doing we are inferring mat technology might or ought to be limited by chronological age. There is often me assumption that all persons over some age, usually 80 or 85, are all "sick" or very disabled. The fact is that He majority of persons who are 85 are living at home and have either no limitations or only one minor limitation in their activities. Further, a healthy 85-year-old may have more years of high-quality survival than a 50-year-old with severe

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120 L. GREGORY PAULSON chronic respiratory disease. Far more equitable and humane would be to consider the application of technology in relation to He seventy of illness and disabilities, the likelihood of improvement, and the anticipated life expectancy. Only in the very extremes of life, at 100 or more, is age a reasonable proxy for life expectancy. FOCUS ON LIFE EXTENSION AND FEAR OF DEATH Those familiar with intemational health, even in developed west- ern nations, are often struck by the preoccupation of persons in the United States with life prolongation and what seems to be our national death phobia. In addition, we seem to take the approach that ad technologies of "possible" benefit must be applied in almost every situation. Because of ese~tendencies, and the demographic changes that we have experienced and win continue to experience at an even more accelerated pace, He cost of care for those over 65 win continue to grow rapidly. It is instructive to note that the major driving force in the increase of costs in Medicare expenditures is not population growth or price increases, but increased use and intensity of service in bow inpatient and outpatient settings. To illustrate He effect of our tendency to apply technology at shorter-and shorter life expectancies and in situations of questionable efficacy, ~ would like to use an old trick question from junior-high math: What amount of time win it take you to reach a was 10 feet away if you travel half the remaining distance to the wan every 5 seconds? The same answer inflateapplies to the mathematics question as weU as to the question of what is the marginal cost of technology applied to situations of ever lower efficacy or to persons with very short life expectancy. This implies that even if we are willing to limit technology by eliminating those interventions that are of zero or negative effectiveness, we still will pay relatively large amounts for infinitely small gains in health. DATA FOR MAKING DECISIONS ABOUT TECHNOLOGY USE BY OLDER PERSONS l One of the more difficult aspects of geriatric medicine is He lack of information concerning the efficacy of the interventions we use with our patients. Many studies of technologies, be they drugs or devices, do not have a representative sample of the population Hat may be most likely to use the technologynamely the older person win multiple health

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ACUTE HOSPITAL CARE: SYSTEM RESOURCES AND CONSTRAINTS 121 problems. This adds to me data problems that we have wad our health care system in general. For example, In most areas of health care, including Medicare, it is virtually impossible to trace even utilization of resources, much less outcomes, Hugh the course of an illness. Susan Foote, in her analysis of key technology assessment issues (5), cites the lack of infonnation about the efficacy and cost-effectiveness of medical technology as one of the key factors that limits our ability to rationalize health care technology. Win bow drug and device technologies, we have a reasonable knowledge of me safety of He entity, and in the case of drugs, even the initial efficacy. However, once the drug or device is initially approved, our ability to follow He subsequent diffusion, new applications, or long-term effects, either beneficial] or ha~Tnfid, is very limited or nonexistent. With most new procedures there may not even be scientifically valid information concerning their basic effectiveness be- fore they become widely disseminated. NEED FOR REGULATION OF TECHNOLOGY I realize that for many, attempts to regulate technology are seen as leading to stifling of innovation and progress. Yet at some level the percentage of our gross national product (GNP) that is being spent on medical care win be unsustainable. Whether that level is 15 percent or even higher is not He issue. We simply cannot continue to apply medical technologies with lithe attention to their marginal effectiveness or cost- effec~veness. There would seem to be only Wee possibilities to control- ling technology: to reduce expenditures on basic research and technology development; to control He diffusion of technology; or to allow rationing at the point of delivery. ~ believe that it would be unwise to in any way constrain basic biomedical research, largely because of its potential to create breakthroughs, like the polio vaccine, Hat are not only very effec- tive but often replace high-cost technologies. Rather Han de facto ration- ing based on tile ability to pay (like the need for "u~front" payments for heart and liver transplants in some instances), ~ would propose that we more closely control the diffusion of technologies through both effective- ness analysis and reimbursement policy. One step would be to allow only those groups that are willing and able to supply careful follow-up data to use technologies after they have been determined to be safe but before we have accurate data on effectiveness and cost-effectiveness. In addidon, there would be regular reviews of He use and effectiveness of a specific

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122 L. GREGORY PAULSON technology using longitudinal patient-specific data This ongoing surveil- lance is necessary because of the tendency of many technologies to be applied in new areas of unproven benefit. A joint private sector and federal government agency with involvement but not control by health professionals might be the best vehicle for this activity. REIMBURSEMENT AND FINANCING Because of the complexity of this area, ~ win be of necessity very brief and more superficial than ~ would like to be. However, not to recognize the driving force of our reimbursement and financing system for health care on the use and abuse of technology win the older persons in this country would be unfortunate. No technology policy can be effective without close attention to reimbursement policy. We now make reimbursement decisions about He initial use of technologies based on what health care providers decide to charge and at a time when our knowledge about the technology is often rudimentary. There is no sys- tematic review of the level of reimbursement or total expenditures on a technology in relation to its overall effectiveness. Furthermore, in our major publicly financed program, Medicare, we readily reimburse very generously for tertiary care technologies, and yet fail to provide adequate coverage for such proven preventative measures as influenza vaccine and screening PAP smears and breast examinations. An element that underlies most of the problems that I have dis- cussed is the conflict, almost unique in this country, between our love affair with pAvate enterprise and our increasingly strong belief in heady care as a right, one that should not be rationed on the basis of ability to pay. You simply cannot mandate that everyone should have access to medical care technology and expect the free enterprise system to function as He optimal way of distributing that technology. Until we are able to provide a better resolution of this basic issue, we win continue to use medical care technology in our entire population in a less efficient manner than is desirable. REFERENCES I. U.S. Congress. Office of Technology Assessment. Medical Technol- ogy and Costs of tile Medicare Program. OTA-H-227. Washington, D.C., U.S. Govemment Printing Office, July 1984.

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1 AClJ~17EHOSPITALCARE: SYSTEM RESOURCES AND CONSTRAINTS 123 2. U.S.Congress. Office of Technology Assessment. Technology and Aging in Amenca. OTA-BA-264. Washington, D.C., U.S. Govem- ment Plinting Office, June 1985. 3. U.S. Congress. Office of Technology Assessment. Life-Sustain~ng Technologies and the Elderly. OTA-BA-306. Washington, D.C., U.S. Government Pruning Office, July 1987. 4. Garrison, L.P., and Wilensky, G.R. Cost containment and incentives for technology. Heal Affairs 52:45, Summer 1986. 5. Foote, S.B. Assessing medical technology assessment: Past, present, and future. The Milbank Quarterly 65~:5~80, 1987.