Council: issues on aging call for presidential panel.(Practice Trends)

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 ...