Money-Strapped, Dependent, and Aging

What is to be done when the body is falling apart, healthcare and affordbility are clashing, and the things that an individual values in life are in the throws of transition? The solution is complex. Settling upon a decision that satisfies patients with life-threatening illnesses and the patients' families requires trust, openness, and honest conversations.

While I let that simmer, let's briefly talk about healthcare pricing. On average, a retirement community will cost $32,000 per year. Retirement communities also require the resident to pay an entry fee. The fee covers services throughout the duration of the resident's stay. A resident may begin living in the community at the age of 62, and may stay there until the age of 83. Due to the possiblity of a long duration of stay, the entry fees for retirement communities are quite expensive. Atul Gawande places the figures between $60,000 and $120,000. There are several methods of entry fee payment:

Declining scale refunds specify a period of time in which the entrance fee will be refundable to the resident on a declining basis. For example, if an entrance fee under this arrangement declines at the rate of 1 percent each month, after 6 months 94 percent of the entrance fee is refundable.

Partially refundable entrance fees guarantee a specific percentage of the refund that will be returned within a certain period of time regardless of the term of residency. For example, 50 percent of the entrance fee may be refundable upon termination of the contract or to the estate upon the resident’s death. The point to remember about this method is that the 50% refund will only be available if the resident dies after a certain amount of time. The entry fee is meant to serve as compensation throughout the resident's entire stay within the community, therefore the refund period may be a number of years.

Full refunds offer just that, a full refund of the entrance fee. A fixed charge may be deducted before the refund is made, and the agreement generally states how long the refund is valid and under what conditions a refund is due. Entrance fees that offer full refunds are typically more expensive than those without refunds or those that are partially refundable or refundable on a declining basis.

Regardless of the method of payment, rent and entry fee will cost tens of thousands of dollars. Even at the cheapest estimation, the cost of the first year of stay will be just over $90,000 per year on average. After the entry fee is paid, there is still the obligation of monthly rent for residing within the community. This is a steep price for someone that is retired. If the resident is getting assistance from family members, they too will be burdened by the cost of the retirement community.

As I've discussed in prior posts, autonomy and fulfillment are extremely important when dealing with elderly patients. Gawande harkens back to this point throughout the entirety of the book, and it is something that I will carry with me for the rest of my life. Gawande also mentions that the most common complaint he's heard from residents is, "it just isn't home". In old age and decreasing health people want to make decisions for themselves and live in a place that feels like home. People want to have visits with friends and family, decide when and what to eat, choose the pace of their day, and make decisions about their present and future. Often independent living facilites strip away independence. The focus shifts to avoiding potentially harmful situations and the resident is under keen vigilance. This may please the families temporarily, but they too come to see the growing unhappiness of their loved ones. The procedures and barriers that create a more safe environment are the very ones that become hinderances to autonomy and the feelings of being at home. In my opinion families leave their loved ones in hyper-vigilant, unhappy living situations because they do not know what else to do. They want to provide a stimulating and fulfilling living environment, but families are unsure if they have the ability to incorporate the needs of an ailing patient into their home. Families are doubtful that they will be able to fit another person into their home, afford to care for another person, and allocate the time to cater to the needs of a person that may not be able to fully care for themselves. While reading this book I've been reminded of the differences between assisted living, nursing homes, and retirement communities. I'm going to skip comparing and conrasting them for now, but I may explain there respective functions in a future blog for the purpose of anyone who is reading and unsure of the differences between the three. If you would like historical background, it may be worth doing a quick investigation into the history of the transition from poorhouses to hospitals and nursing homes.

For better or for worse, nursing homes, in their present state, are entrenched in the U.S. medical system. Gawande mentions several transitional steps that have influenced the modern function of nursing homes. Among those mentioned was the period of substantial compliance, which seemed to have the most significant affects. Gawande contends that nursing homes, and the culture of care that surrounds their day-to-day functions, does not cater toward the needs of patients that are facing dependency and old age...and I agree. Many nursing homes around the country are used as overflow. These nursing homes house the elderly patients that the hospital is unable cure. The comorbidity and deteriorating health of such patients has become a strain on hospitals. What does a place of medicine do with an incurable patient? Elderly patients are herded into the limbo of a nursing home lifestyle; and for many patients, families, and providers alike, the transition is daunting.