# Presentation: 186985

## Decision Challenges in Health Care

- Alan M. Garber
- Center for Health Policy/Center for Primary Care and Outcomes Research
*Stanford University*

## Center for Advancing Decision Making for Aging

- Stanford’s Roybal Center
- Medicine, Economics, Psychology collaboration
- Alan Garber PI, Laura Carstensen co-PI
- Provides seed funding for junior faculty/advanced trainee projects
- All the current and planned work discussed here supported by NIA

- _Incorporating Health Preferences of Older Adults into the Electronic Medical Record_ Amar Das, MD, PhD
- _Affective Forecasting and Decision Making in Older Adults_, Brian Knutson, PhD
- _Age Differences in the Processing of Health Care Information_, Joseph A. Mikels, PhD

- _Age Differences in Emotional and Cognitive Decision-Making_ Ian H. Gotlib, PhD & Elaine R. Robertson, PhD
- _Risk-Taking and Financial Decision-Making in Older Adults_ Gregory Larkin, PhD, Brian Knutson,PhD, & Camelia Kuhnen, MBA:

## Difficult Health Care Decisions at Advanced Ages

- End-of-life care
- Treatment choices
- Selecting high-quality health care providers
- Health plan choice (supplemental insurance, Medicare Part D)

## Life-Threatening Illness

- Treatment for cancer often toxic and expensive
- Erbitux - $9,600/month
- Avastin for lung and breast cancer - $8,800/month
- Would you want very aggressive care?
- Should Medicare cover it?

## Stanford alumni various ages

- 20-35 year olds: 31
- 35-59 year-olds: 39
- 60-87 year-olds:  31

## Scenario

- 	Imagine that you have just received a diagnosis of pancreatic cancer, a serious life-threatening disease that can cause considerable discomfort and is difficult to treat. Your doctor tells you that without treatment it is unlikely that you will survive for more than a year.   Please answer the following questions about possible options.

## Treatment options

- Option 1: Relatively new and untested treatment that takes one year to administer, is relatively painless but side-effects are not well known.
- Option 2: A combination of chemotherapy and radiation therapy that takes one year to administer, has very uncomfortable side effects.
- Option 3. Treatment focuses on comfort, including treatment of pain and discomfort, hospice care, and support for you and your loved ones in managing your household and helping you stay in your home as long as possible.
- Option 4. Hospital intensive care with life support at the end of life.

## Variables

**Time perspective**: Number of additional years treatment might give you (1 or 10 years)
**Life or death frame**: “extend/prolong your life” or “postpone/delay your death”
**Chance treatment will work**: “relatively low” or “good”

## Questions

- How likely are you to want this option?
- 	1              2               3               4              5                 6               7
- Not at all likely ----------------------------------------------------------------Very likely
- How strongly do you feel that Medicare should pay for these options?
- 	1              2               3               4              5                 6               7
- Not at all strongly ----------------------------------------------------------Very strongly

## Option 1

- Percentage wanting new treatment, by age group:
- Young: 		48.4%
- Middle-aged: 	64.1%
- Old: 		44.8%
- Percentage wanting Medicare to pay for new treatment, by age group.
- Young: 		58.1%
- Middle-aged: 	71.8%
- Old: 		56.7%

## Wanting new treatment

- Chance treatment will work, F(1,93)=3.800, p=.054
- 	More likely to want treatment if it is thought to have a good chance of working.
- Age group X Chance, F(2,93)=3.507, p=.034
- Young and middle-aged more likely to want new treatment when chances of success are good, whereas old do not show this change in preference.
**No predictors of wanting Medicare to pay for new treatment.**

- *

## Option 2: Traditional treatment (chemo & radiation)

- Percentage wanting chemo & radiation, by age group:
- Young: 		29%
- Middle-aged: 	38.5%
- Old: 		16.1%
- Percentage wanting Medicare to pay for chemo & radiation, by age group.
- Young:		83.9%
- Middle-aged:	84.6%
- Old:		60%

## Wanting traditional chemotherapy treatment

- Age Group, F(2,89)=4.508, p=.014
- Middle-aged most likely to want treatment.
- Old vs. Middle-aged (p=.006)
- Chance treatment will work, F(1,89)=10.634, p=.002
- More likely to want treatment if it has a good chance of working.

## Should Medicare pay for chemotherapy?

- Age group, F(2,88)=2.827, p=.065
- Older adults least likely to want Medicare to cover traditional treatment.
- Old vs. Middle-aged (p=.081)
- Time perspective, F(1,88)=3.853, p=.053
- Payment preference increases when treatment offers 10 (vs. 1) additional years of life.
- Chance treatment will work, F(1,88)=7.758, p=.007
- Less likely to want treatment if it has a poor chance of working.

## Option 3: Comfort Care

- Percentage wanting comfort care, by age group:
- Young: 		56.7%
- Middle-aged: 	74.4%
- Old: 		54.8%
- Percentage wanting Medicare to pay for comfort care, by age group.
- Young:		71%
- Middle-aged:	94.9%
- Old:		77.4%

## Wanting comfort care

- When treatment options (in prior questions regarding new treatment or traditional treatment) are presented as having a low chance of success, participants are more likely to want comfort care.
- Chance treatment will work, F(1,94)=9.866, p=.002
- No age effect.

## Should Medicare pay for comfort care?

- Age group, F(2,98)=3.999, p=.021
- Young vs. Middle-aged (p=.016)

## Option 4: Intensive Care

- Percentage wanting intensive care, by age group:
- Young:		29%
- Middle-aged:	12.8%
- Old:		6.9%
- Percentage wanting Medicare to pay for intensive care, by age group.
- Young:		61.3%
- Middle-aged:	51.3%
- Old:		39.3%

## Wanting intensive care

- Age group, F(2,96)=4.592, p=.012
- Old vs. Young (p=.009)

## Should Medicare pay for intensive care?

- Age group, F(2,92)=4.154, p=.019
- Old vs. Young (p=.015)
- Old vs. Middle-aged (p=.068)
- Life or death frame, F(1,92)=4.741, p=.032
- If ICU will “delay death” it is preferred to when it is described as “prolonging life” – a sort of inverse negative framing effect.
- If ICU described as “prolonging your life” one is less likely to want it as one gets older; if it “delays your death” you are more likely to want it overall.

## Preference for type of Medicare Plan

- Percentage wanting plan focusing on comfort and quality of life, by age group:
- Young:		75.9%
- Middle-aged:	79.5%
- Old:		88.9%
- Percentage wanting plan providing hospital & treatment services regardless of life expectancy and quality of life concerns, by age group.
- Young:		24.1%
- Middle-aged:	20.5%
- Old:		11.1%

## Complex Health Plan Choice

- Choosing a Medicare drug plan

- _[http://](http://www.medicare.gov/)__[www.medicare.gov](http://www.medicare.gov/)__[/](http://www.medicare.gov/)_

## Slide 25

**Notes:**
Medicare Prescription Drug Coverage (1 of 2)

## Slide 26

**Notes:**
Medicare Prescription Drug Plan Finder (2 of 2)

## Slide 27

**Notes:**
Find a Medicare Prescription Drug Plan

## Slide 28

**Notes:**
Personalized Plan Search

## Slide 29

**Notes:**
General Plan Search (using Zip Code)

## Slide 30

**Notes:**
Decide on Plan Options

## Slide 31

**Notes:**
Current Plan Type

## Slide 32

**Notes:**
View List of Prescription Drug Plans available in Zip Code 95350 (1 of 2)

## Slide 33

**Notes:**
Continued from previous slide (2 of 2)

## Slide 34

**Notes:**
List of 48 available plans (1 of 3)

## Slide 35

**Notes:**
Continued from previous slide (2 of 3)

## Slide 36

**Notes:**
Continued from previous slide (3 of 3)

## Slide 37

**Notes:**
Drug Finder

## Slide 38

**Notes:**
Drug Finder search by drug name

## Slide 39

**Notes:**
Update drug dosage

## Slide 40

**Notes:**
Review drug list

## Slide 41

**Notes:**
Plan Comparison (1 of 3)

## Slide 42

**Notes:**
Continued from previous slide (2 of 3) – Pharmacy Selection

## Slide 43

**Notes:**
Continued from previous slide (3 of 3)

## Slide 44

**Notes:**
Compare up to 3 plans (1 of 2)

## Slide 45

**Notes:**
Continued from previous slide (2 of 2)

## Slide 46

**Notes:**
Enrollment Form (1 of 4)

## Slide 47

**Notes:**
Enrollment Form (2 of 4)

## Slide 48

**Notes:**
Enrollment form (3 of 4)

## Slide 49

**Notes:**
Enrollment Form (4 of 4)

## Decision Challenges

- Choices facing older Americans likely to become more complex and more consequential
- Improving the ways we frame choices
- How to determine whether a choice is optimal or even successful
- Can we employ knowledge of changes in emotional processing and cognitive performance with age to improve design of cho