May 09, 2008

The Boomers are Coming, the Boomers are Coming

I often wonder just how many billions of dollars Americans spend every year on producing reports. Think tanks, government agencies, and academic departments, not to mention corporations, are forever releasing reports. Most of them are filed away, largely unread, certainly unheeded. Every so often a report actually has a major impact—on policy, on behavior, or on public understanding. The Surgeon General’s Report, The Health Consequences of Smoking, first released in 1971, led to a campaign to promote health by quitting smoking. As a result, per capita cigarette consumption is down in the U.S., as are the incidence of lung cancer and the death rate from heart disease, the primary diseases attributable to smoking.

Several weeks ago, the Institute of Medicine released a new report, Retooling for an Aging America: Building the Health Care Workforce. With luck, this will be one of those reports that triggers a response, but given its low key presentation, unsexy topic, and unpopular message, I fear it will be ignored.

Written in the non-inflammatory, academic style of the IOM, Retooling quietly argues that if we are to provide high quality care for the baby boomers in their old age, we need to geriatricize both health care professionals and personal caregivers. In an equally subdued voice, the report’s writers also conclude that we need to overhaul our entire approach to medical care. They’re right. I hope someone is listening.

The first of the 78 million baby boomers will turn age 65 in 2011. When the last baby boomer turns 65 in 2030, “older adults” will make up 20% of the population, up from the current 12%. Unless we find a cure for Alzheimer’s disease in the immediate future, which is extremely unlikely, and unless we can prevent or cure osteoarthritis, diabetes, and vascular disease, the boomers will develop all these problems in phenomenal numbers. Although they will be healthier than their counterparts a decade ago, many will eventually develop multiple medical problems and will need both health care and personal care if they are to hope to have a reasonable quality of life.

What the new IOM report tells us is that we do not have enough physicians, nurses, social workers, and physical therapists with special expertise in taking care of older adults to handle this enormous wave. We do not have enough home health aides and other personal care attendants to assist older people with basic “activities of daily living” such as dressing, bathing, and eating, given that we can expect that in 2030, over 9 million people will need this kind of help (that’s based on another important report, this one by Robert Friedland, writing for the Georgetown University Long-Term Care Financing Project in 2004: Caregivers and Long-term Care Needs in the 21st Century: Will Public Policy Meet the Challenge?) And informal caregivers—the family members and friends who provide the bulk of the care to frail older Americans—are already overwhelmed physically, emotionally, and financially by their responsibilities.

Retooling for an Aging America tells us very clearly what steps we need to take to begin to fix this problem. It uses the bland language of “increasing recruitment and retention” of personnel, but quickly gets to the central issue: few people are going to jump at the chance to take care of the elderly, whether they be physicians, nurses, or home health aides, unless they receive appropriate recognition, social and financial, for their work. That means compensation needs to go up—a lot. Currently, geriatricians earn on average less than the primary care physicians who see a more diverse population of adults, who in turn earn far less than gastroenterologists or cardiologists. Taking care of frail older people takes extra time, it requires coordination of multiple services, and it necessitates discussions with family members, all of which are reimbursed poorly or not at all. The suggestion that public and private payers provide financial incentives to increase the number of geriatric specialists in all health professions is key. So too is the recommendation that professionals with special expertise in geriatrics receive enhanced reimbursement, though given budgetary constraints, it seems more plausible that physician incomes will need to be redistributed than that payment to those on the bottom end of the totem pole will rise. Similarly, aides who provide hands on care for older people are among the most poorly paid workers in our society, they have the highest rates of on the job injury, and they have few opportunities for advancement. Without better wages, adequate fringe benefits, and an attractive career ladder, it’s hard to imagine the situation will change. The recommendation that state Medicaid programs increase pay and fringe benefits for direct care workers and establish wage floors is an important first step. It does not, however, go nearly far enough, and is not as sweeping as another report that is probably already collecting dust—the study prepared by the much maligned President’s Council on Bioethics in 2005, Taking Care: Ethical Caregiving in Our Aging Society.

It is in the arena of “redesigning models of care” that the report is at its most radical. It begins with the tepid comment that “care that is currently provided to older adults often falls short of acceptable levels of quality.” Then it heats up a bit, acknowledging that the vision of health care services it proposes represents “a major departure from the current system” that will require changes in the ways services are “organized, financed, and delivered.” The report recommends three fundamental changes: care must be comprehensive, it must be efficient, and it must rely on the active participation of older adults.

By comprehensive care, the report means that our current fragmented system has to go. Right now, Medicare doesn’t have an incentive to provide home care because it would be cheaper for patients to go into a nursing home (paid by Medicaid or private funds) than it is for patients to stay at home and have a visiting nurse and physical therapist (paid by Medicare). Today, physician practices shy away from using multidisciplinary teams, the backbone of good geriatric care, because this kind of care is inadequately compensated. Comprehensive care means including both acute care and long term care (at home, in assisted living, and in nursing homes--currently the stepchild of the American health care system) under one umbrella.

By efficient care, the report means that we need to create seamless transitions between the sites where older people receive health care such as the office, the hospital, the skilled nursing facility, and the home setting. This will require better systems of communication and widespread adoption of a single electronic medical record.

By active participation, the report implies that effective management of chronic diseases—and almost a quarter of Medicare beneficiaries have at least 4 chronic diseases—requires self-management. Given that many older patients cannot, by themselves, engage in self-management, a more realistic recommendation would be the involvement of families in all aspects of health care.

So far, Retooling has been written up in the Wall Street Journal and the LA Times but not, as best I can determine, in the New York Times or the Washington Post. This mild-mannered report, which makes reasonable suggestions but says little about how its recommendations might be implemented (or paid for) could well be destined for the dustbin. Let’s hope not. We really need to do something to prepare for the baby boomers, and we need to start now. Write your congressman. Whisper in the ear of the presidential candidates, who have said little or nothing about long term care. Act now.

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