Universal and equal access to effective health care services

Zdenek Kalvach

Factors of universal and equal access to health care services 1

• Financial accessibility– Fee for services– Health insurance covering– Poverty in old age• Gender aspect: lonely women (widows)

– low pension – worse health state – health expectancy, disability, frailty,

sarcopenia, osteoporosis, dementia– more unhealthy years of life (DFLE = Healthy life years, HLY)

Factors of universal and equal access to health care services 2

• Regional accessibility of health care facilities– Distances– Density of the health care network– Concept of community primary care

• Local accessibility– Barriers • Barrier-free environment• Wheelchair accessible facility, transport

– Universal, age-friendly design

Factors of universal and equal access to health care services 3

• Discrimination– Racism – unequal approach to (old) gypsies– Ageism – including formal age limitations of some

health performances – f.e. hemodialysis over 65– Frailtism • inappropriate restriction in health care of the frail

elderly – toward to cheaper, less sofisticated, less effective care • discriminatory de-medicination, inappropriate

exclusion from the health care

De-medicination -a dangerous misunderstanding

• Humanistic de-medicination to submit health care to natural life– Protection of dignity, meaning of life, social roles– Personalized medicine– Humanization of approaches to geriatric, frail

patients• Reductionistic, discriminatory de-medicination

to exclude the frail elderly from needful care– Basic nursing instead of appropriate medical care

De-medicination -a dangerous misunderstanding

It´s strictly necessary to draw a line between • Useless expenditures = expenditures for

generally useless cure (therapy or diagnostic performances)

• Useless expenditures = expenditures for generally useful cure of „useless“ people (the frail elderly)

Of course it´s inadmissible to distinguish useful and useless people but …

Overpopulation – the mankind , the elderly, sick or slowly dying people?

Pragmatism of economic governance by Niccolo Machiavelli (1469-1527)

Factors of universal and equal access to health care services 4

• Low compliance of patients and caregiving families– Asocial behaviour – homeless elderly with addict– Health illiteracy• Lack of knowledge about

– health in old age– Improvement of deficits and complaints of old age– potential health care services for the frail elderly

Factors of universal and equal access to health care services 5a

• To get inside is not enough - Geriatric illiteracy of health care system and the most of physicians 1. In the framework of the disease model - the world

of index diseases:• Mistakes and neglect because of atypical clinical

manifestation of diseases in old age• Adverse effects of medication and other treatment• Geriatric hospitalism – iatrogenic lost of self-sufficiency,

break of dignity, overstress, complications of stay• Catastrophic management of geriatric giants + nutrition

Geriatric giants of Bernard Isaacs

Catastrophic hospital management of geriatric giants • instability • Immobility • Incontinence• intellectual impairment

– delirium (confusion)– dementia

(maladaptation)

Thomas Jefferson (1743-1826) – a prophet of geriatric mistreatment?

„There is nothing more unequal than the equal treatment of unequal people.“The quote attributed (with a question mark) to the 3rd elected president of U.S., the man of Declaration of Independence

Unequal outcomes can be consequences of equal treatment

Equity of what -Equal approach or equal outcome?

• Equity in approaches (input) – „the same to all“ (socialism in the practice) – Easy standards – society fascinated by

• Normative standards• Unification • Replaceable elements

– Discrimination of people with specific needs, difficulties

– Through the same treatment to different outcomes

Equity of what -Equal approach or equal outcome?

• Equity in outcomes (output) – „the same effectivness to all“ – Individualisation– Individual understanding – Specialised approaches to the frail geriatric

patients with special needs and risks – geriatric affirmation

– Through the different treatment to similar outcomes

The ancient alchemical axiom

• In the world of (original) components there is no place for equivalents.

• In our worl of (standardized, unified) equivalents there is no place for (original) components.

Factors of universal and equal access to health care services 5b

• Geriatric illiteracy of health care system and the most of physicians 2. Beyond the disease model - the world without index diseases:• Functional health• Frailty• Multicausal disability with weak link to index diseases• Multicausal geriatric syndromes • Exclusion of the frail patients without index diseases

Frailty – pathological deterioration in old age

• More than natural biological involution• Much more than a new disease or syndrome• A keystone of basic approach of the society and

its health care system to the frail, disabled, very old people

• A basic question of purview of medicine and health insurance – medical priority or social affair?

• „We won´t allow medicination of natural ageing“ – also medical challenges of frailty?

What does have I. Semmelweis in common with R. MacNamara? (NYT)

Connection between I. Semmelweis and R. MacNamara

Low-cost measures with extraordinarily substantial outcomes• I. Semmelweis (1818-1865) – Hungarian obstetrician,

pioneer of antiseptic procedures, „savior of mothers“ (puerperal fever) – wash your hands

• R. MacNamara (1916-2009) – American business executive, Secretary of defense, president of the World bank, as president of Ford´s comp. enforced the seat belt

Geriatrics

Geriatrics has been a field of a low-cost medicine with substantial outcomes because of good knowledge of both the proper patient (multidimensional comprehensive geriatric assessment) and common geriatric challenges including frailty and its effective interventions.

Core of geriatric discrimination and outcome inequity

Low medical responsibility and taking into consideration of complaints of the frail elderlyAbove all beyond the disease modelMisunderstanding and underestimation of frailty.Mainstreaming of frailty or medical neglect?

What´s beyond the disease model

• Health condition• Deterioration, wasting away, fatigue, decline

of health potential– un-diagnosed diseases– challenge to functioning, „setting“ of the organism

• Frequently a multicausal proces • Common un-patognomic symptoms• Disability without index diseases

A. Antonovsky 1923-1994

A. Antonovsky

• Health and disease/sickness create a continuum

• Health is more then absence of diseases• Challenges for medicine:– Diseases – diagnosis, treatment, prevention,

rehabilitation– Health – salutogenesis– Interventions „beyond the disease model“

Consequences of A. Antonovsky´s concept

• Questionable consequences: stress on social welfare

• Useful consequences: there´s something substantial, there´s responsibility of health care system beyond the disease model

The end of the disease era?

• New balance between interest of diseases and interest of other factors of „functional health“

• Mainstreaming of patients with complaints without index diseases – including the frail geriatric patients

• Tinetti M, Fried T. „The end of the disease era“ Am. J. Medicine, 2004

Tinetti M, Fried T. The end of the disease era. A.J.M. 2004

„The time has come to abandon disease as the focus of medical care. The changed spectrum of health, the complex interplay of biological and nonbiological factors, the aging population, and the interindividual variability in health priorities render medical care that is centered on the diagnosis and treatment of individual diseases at best out of date and at worst harmful.

Tinetti M, Fried T. The end of the disease era. A.J.M. 2004

A primary focus on disease may inadvertently lead to undertreatment, overtreatment, or mistreatment… Clinical decision making for all patients should be predicated on the attainment of individual goals and the identification and treatment of all modifiable biological and nonbiological factors, rather than solely on the diagnosis, treatment, or prevention of individual diseases.

Tinetti M, Fried T. The end of the disease era. A.J.M. 2004

Anticipated arguments against a more integrated and individualized approach range from concerns about medicalization of life problems to "this is nothing new" and "resources would be better spent determining the underlying biological mechanisms.„

Tinetti M, Fried T. The end of the disease era. A.J.M. 2004

The perception that the disease model is "truth" rather than a previously useful model will be a barrier as well. Notwithstanding these barriers, medical care must evolve to meet the health care needs of patients in the 21st century.“

Spiral pathogenesis of multicausal frailty (J. E. Morley)

Summery

• There are several factors interfering with universal and equal acces of the elderly to effective health care services.

• Misunderstanding and underestimation of frailty and other challenges beyond the disease model belong to the most important factors.

• It leads to medical neglect, needless suffering, low quality od life, dependency and …

Summery

• Exclusion of the many misunderstood frail elderly from medical responsibility to the social basic long-term care.