Promoting Advance Directives, Reducing Medicare Spending

More and more people are living to the age of 100. As people grow older, the importance of having an advance directive is crucial in making health care decisions, which may reduce overall cost of end-of-life care. While Medicare guarantees access to health insurance for certain Americans and lawful residents aged 65 and older, the program faces significant fiscal challenges over the long-term. Advance directives may reduce Medicare spending since older adults can opt out of aggressive medical intervention by dictating their wishes in the event of a life threatening illness. As Congress continues to debate over the best way to fix Medicare, costs will likely increase if older adults continue to ignore advance directives.

Living Will document with pen, closeupAbout 27.4 percent of Medicare expenses for the elderly are spent in the last year of a person’s life. Advance directives can reduce that percentage because older adults may not prefer lifesaving machines that impact costs. If a person wants to avoid lifesaving machines without having an advance directive, doctors will keep such people alive at the expense of other patients. The latter will be deprived of necessary medical treatment and hospitals may become overcrowded. Also, these machines and other medical resources will contribute to the cost of care because they are expensive and scarce. Unless people write binding living wills, families are reluctant to “pull the plug”, and medical professionals are afraid of being sued if they do. Increasing the use of advance directives is necessary in preventing such problems.

Studies have shown that adults are more likely to complete advance directives that are written in everyday language and less focused on technical treatments. However, many people are currently unaware of advance directives and even fewer complete them. Since advance directives are very lengthy and tedious to complete, most seniors prefer family surrogates. The present state of health care systems also compounds the problem. For instance, there are only two states that offer living will “registries”. Residents can file their living will and allow doctors and other health care providers to have access to their documents. However, the Washington State living will registry has been closed by the state government because lack of funds, among other problems.

If insurance pools take into account the costs spent on people that will never get well, premiums for younger and healthy people are going to be very expensive. It is difficult when people are without an advance directive and do not want lifesaving machines. At the same time, if such people want invasive and aggressive medical treatment in poor prognosis states, then health systems should accommodate and respect their wishes.

Advanced directives are not only for the elderly. Our society is getting older and people have to deal with it. Health professionals need to determine effective ways of promoting advance directives among elderly patients. For example, a study showed that a replicable intervention mainly targeting doctors achieved a moderate increase in advance directives among elderly ambulatory patients. Future interventions may need to address doctors’ attitudes and comfort discussing these documents since patients cite their physician most often as the one who influenced them most to make a health behavior change. Increasing the use of advance directives among elderly persons is important since it reduces Medicare spending and the national budget concurrently.

Living wills and health care proxies need restructuring hence these documents have to be well prepared to reduce confusion, jargon and ambiguity. It is also important for health care institutions to advocate and support the use of advance directives. More states should invest in living will registries and promote advance directives to increase enrollment. If a patient has an advance directive and requests lifesaving machines, families and health professionals should respect their wishes. In the long run, advance directives are necessary because they can reduce overall cost of end-of-life care for individuals and families.

Sophie Okolo is the Founder of Global Health Aging.