Potential Strategies for Stakeholders
An aging population strains national budgets of countries with
extensive social welfare programs. Most countries fund these
programs on a pay-as-you-go basis, and few countries have a
fully funded system. Governments have several levers that can
be pulled to address the changing demographics.
One such lever is financing. Governments should address solvency concerns and ensure programs are sustainable into the
future. Possible approaches could include increasing taxes or
adjusting enrollee contributions (e.g., varying contributions by
income). These approaches are not politically easy or palatable
by citizens but may be necessary.
Legislation is another possible lever. Laws and regulations
could be used to improve the efficiency of health care systems
and direct resources to the most appropriate and effective responses. For example, current reimbursement methodologies
can create incentives for extreme interventions that don’t improve outcomes or the quality of life, and that may not align
with the needs of the population. These methodologies could
be changed to improve incentives, align patient and provider
desired services, and improve quality. Japan, for instance, has
issued guidelines for home care support clinics and introduced fee schedules for clinics registered for provider-planned
home care. 16
Contribution requirements and eligibility rules also could be
used. The simplest example would be to adjust contributions by
income, depending on a nation’s health care system. Additionally,
eligibility for certain benefits could be changed. For example, the
criteria used to determine hospice eligibility could be changed
to make this benefit a more effective option for end-of-life care.
Integration of the various forms and levels of health care is
important, and can improve service and quality of life of patients
while saving costs. Israel, for example, has a National Health Act
that provides health care from conception to death—including
palliative care—for all the residents of Israel. It is integrated
with wide-ranging public community services, long-term care
coverage available to about 70 percent of the population, and—
in particular—many volunteer community groups and services.
Finally, benefits could be adjusted by aligning covered services and cost sharing to incentivize utilization of services. For
example, in China, palliative care is not provided or reimbursed
through its health care system, 17 and patients and their families
must pay fully out of pocket for the care, which deters utilization. This adjustment, however, must be done in the context of
the needs of the covered populations.
Individual communities may also assist in improving the care
for the elderly at the end of life. Approaches will vary based on
demographics, income levels of the community, and the availability of health care. One good example of how a community is
coping with these issues is Kerala, India. 18
Although India as a country ranks at the bottom on the “
Quality of Death Index,” there is a community-based end-of-life care
system in Kerala that has served as a model for many other communities across the globe.
This model is based on the principles that the community
should be empowered to take the ownership of end-of-life care,
and that the service should be made accessible to individuals
and families at a cost the community can afford.
The Kerala model is built upon a neighborhood network of
volunteers. They have been trained to identify patients who are
chronically ill and are near the end of their lives. The volunteers
are connected with outpatient-based local palliative care centers
that provide support from palliative care nurses and physicians
who have gone through specialized training on end-of-life care.
Volunteers supplement the health care professionals with psychological, social, and spiritual support that is culturally and
socioeconomically appropriate to the patients and their families.
Progression of Cost for Selected Conditions
Source: AHA CPI analysis, 2012, with contributions from 2012 CTAC data and 2011 Center to Advance Palliative Care data.
Healthy or with
Early onset, chronic
Chronic and Curative Care