SEPTEMBER / OCTOBER 2006

FORUM

Meeting the health care needs of an aging population

The world’s elderly population is advancing rapidly, and with it the burden of chronic disease. What is being done to prepare?

“Aging is the ultimate universal experience,” notes Dr. Robert Butler, president of the International Longevity Center-USA (ILC-USA). It “ties all nations, cultures and societies together.”

Unfortunately, we are also united by our lack of preparedness for the health care needs of the aging population. Thanks in part to advances in medicine and improved sanitation, more people are living longer than ever before. By 2025, the number of people over age 65 will reach 800 million worldwide, up from 390 million today. But the flip side to this increased lifespan is a corresponding increase in age-related chronic diseases. Half of all cancer occurs after age 65 and more than 80% after age 50; coronary heart disease, atherosclerosis, arthritic disease, Alzheimer’s, and other conditions are also closely linked to age. Dementia, falling, and incontinence are among the complex syndromes that impede people’s ability to function independently as they grow old. In the coming decades, this disease burden is expected to stretch the supply of physicians and other health care workers to the breaking point. Even with today’s doctor-patient ratios, studies show that elders are not getting the preventive care they need. According to a report by the ILC-USA, only 10% of people aged 65 and over in the U.S. get screened for bone density, colorectal and prostate cancer, and glaucoma—despite these diseases’ association with old age.

HMI World spoke with some of the physicians, nurses, and researchers on the forefront of this important issue. Each approaches the problem from a different perspective, but all agree that unless societies quickly make managing age-related disease a top priority, the supply of trained health care workers will soon be insufficient to meet the needs of the elderly.

A dearth of geriatricians
One might expect that the U.S. would be one of the better prepared nations when it comes to readying its health care system for the approaching demographic shift. After all, the U.S. has been watching the Baby Boom generation grow up since the 1950s. The U.S. has top-flight hospitals and medical schools with more than enough applicants, and extensive continuing education opportunities. And yet, the country has been astoundingly slow to take steps to narrow the gap between the supply of services and the anticipated demand.

Potentially more problematic, even as the number of elderly rises, the specialty that focuses on diagnosis and treatment of conditions that affect people as they age is getting short shrift. Fewer than half of U.S. medical schools have geriatric programs. Meanwhile, funding for geriatric health professions was excluded from the FY2007 congressional budget, making it even more difficult for doctors to become trained in the specific needs of elders than it was in the past. Medicare isn’t helping matters. Currently it does not reimburse geriatricians for assessments and the coordination and management of care—the foundation of caring for a frail or impaired older adult.

In this respect, the U.S. lags behind many countries, most notably England and Japan. Every medical school in Great Britain has a department of geriatrics; Japan has 88 medical schools, of which 19 have full departments of geriatrics. The U.S. by comparison has just three geriatrics departments among some 145 medical schools, and only 20 that require geriatric coursework. And while there is roughly one pediatrician for every 1,000 children in the U.S. today, there are only 9,000 certified geriatricians, a figure that represents just 1% of all physicians. According to the Alliance for Aging Research, we need 20,000 geriatricians today and will require at least 36,000 by the year 2030.

Christine Kovner says fewer than one percent of the nation’s RNs are certified in geriatrics.

The situation is no better in the nursing field, says Christine Kovner, PhD, RN, FAAN, senior fellow at the John A. Hartford Institute for Geriatric Nursing and a professor in the Division of Nursing at New York University. She points out that fewer than half of baccalaureate nursing programs have full-time faculty certified in geriatric nursing. In addition, fewer than 1% of the country’s 2.2 million practicing registered nurses are certified in geriatrics and only 30 of the more than 670 baccalaureate nursing programs met all the criteria for an exemplary geriatrics education. Training is also lacking among pharmacists, social workers, and other health care professionals.

Without proper geriatrics training, it’s hard for health care professionals to provide adequate care to their older patients, who average three or more chronic medical conditions, take five prescription medications, and respond to treatments and medications differently than younger people do. The U.S. General Accounting Office estimates that medication-related problems among the elderly may account for as many as 17% of hospitalizations of older Americans and may cost as much as $20 billion a year in hospital stays. (This may be partially explained by the fact that most clinical trials are done with younger people.)

Training the trainers
What’s the solution? Simply churning out thousands of geriatricians clearly won’t solve the problem, even if such a thing were possible. If geriatric training was required in every medical school today it would take more than 40 years for all practicing physicians to be replaced by those with geriatric training, says Greg O’Neill, PhD, director of the National Academy on an Aging Society. He adds that new geriatricians, like people in other medical specialties, tend to cluster, leaving an oversupply in some areas while others remain underserved.

Lewis Lipsitz: “Not every older person needs a geriatrician, but every physician needs some training in geriatrics.”

Some geriatricians—like ILC-USA’s Robert Butler, and Dr. Lewis Lipsitz, chief of gerontology at Beth Israel Deaconess Medical Center, vice president for academic medicine and co-director of the Institute for Aging Research at Hebrew SeniorLife, and professor of medicine at Harvard Medical School—advocate for geriatrics as an academic specialty.

“My approach, and that of my colleagues, is to train the trainers. We want to train the academic leaders who are training the medical students and residents, so that every emerging doctor has a basic knowledge of geriatrics—the way every medical doctor has a working knowledge of cardiology,” explains Lipsitz. “In this way, geriatricians become the researchers who generate new knowledge, as well as the teachers and consultants who disseminate it to the existing  health care workforce”—including physicians, nurses, therapists, pharmacists, and social workers.

Butler echoes these sentiments: “We need to have an adequate group of teachers so that no one graduates without knowing the special issues of aging: drug reactions, pharmacology, and the different presentations of a heart attack.”

No one is saying that geriatricians should leave clinical practice altogether. They are arguing that geriatricians should be used most effectively, not as adjunct primary care providers, but as specialists who focus on the age-related syndromes that fall through the cracks. Dementia, fainting, falls, blood pressure regulation, functional decline, the need for multiple medications, delirium, urinary incontinence, and other complex diseases are all conditions that tend to result from multiple causes and don’t fit neatly into a specialty. “Another way to look at it,” says Lipsitz, “is that rather than being a vertical discipline, focused on one disease or organ, we are horizontal, cutting across all organs and diseases that contribute to the functional problems an older patient might have.”

Or, to put it another way, “Not every older person needs a geriatrician, but every physician needs some training in geriatrics,” says Lipsitz.

Attracting new geriatricians presents many challenges today. Among them are a shortage of role models and mentors, low reimbursement rates, high patient demand, and a lack of glamorous technology attached to the field. The situation is a bit absurd, reflects Lipsitz, because of the enormous potential cost savings. “If proper geriatric care results in a modest 10% reduction in hospital, nursing home, and home care costs, the nation would save $50 billion in health care costs each year.”

Similar arguments have been made about the need for geriatric training among nurses. Research has shown that older patients who get specialized geriatric care from nurses tend to fare better than those who receive the usual care. In one study, patients who got inpatient and outpatient care in geriatric units experienced far less functional decline and showed improvements in mental health, at no additional cost. In another study, older patients cared for by nurses trained in geriatrics had fewer readmissions to the hospital and were less likely to be transferred from nursing facilities to a hospital for inappropriate reasons.

Undoubtedly, a change is needed. But there is some cause for optimism. While the U.S. government has been slow to support geriatrics, foundations are beginning to take up some of the slack. For example, the Donald W. Reynolds Foundation, has awarded 30 grants totaling almost $60 million to support comprehensive projects in academic health centers to train medical students, residents, and practicing physicians in geriatrics. Another leader, the John A. Hartford Foundation, helped to put geriatrics on the map by funding Centers of Geriatric Excellence for physicians and nurses, as well as establishing scholarship programs for nurses and social workers in the field of aging.

And Christine Kovner notes that the Hartford Institute for Geriatric Nursing at NYU’s College of Nursing has also been working with nursing specialty organizations to disseminate information about caring for the elderly, and has gotten 180 hospitals to agree to change the way they deliver nursing care to older adults.

More efficient health care
Reports of a nationwide doctor shortage are widespread. The American Association of Medical Colleges (AAMC) is just one organization that has called for expanding enrollments at medical schools to meet the need for physicians to treat the growing population of elderly.

David Goodman says that more efficient use of the geriatricians we already have is the first step in addressing the perceived workforce shortages.

Dr. David Goodman, professor of pediatrics and community and family medicine at the Center for Evaluative Clinical Sciences (CECS) at Dartmouth Medical School, says that the idea of a doctor deficit is a myth. “The argument that we have an impending physician shortage is based upon simplistic actuarial models of the relationship of the number of physicians per capita adjusted for age and gender,” he says.

Merely calculating the number of doctors across the nation does not take into account the enormous geographic disparities. He calls the AAMC’s estimation of a potential 20% shortage a very small deficit, compared to the 300% to 400% difference regionally reported by the Dartmouth Atlas of Health Care. “Over the last 20 years,” he adds, “growing the physician supply has been ineffective in reducing this regional variation.”

In a study published in the March/April issue of Health Affairs, Goodman and his colleagues at the Center for the Evaluative Clinical Sciences at Dartmouth maintain that the current supply of physicians and medical students will be adequate through 2020, if they are employed efficiently. Their research suggests, however, that there are many academic medical centers that can serve as role models for efficiency, and if the rest of the country were to follow their example, the projected doctor shortage might prove baseless.

Models of excellence and efficiency include academic medical centers at the Medical College of Georgia, (6 full-time-equivalent physicians per 1,000 patients), University of Cincinnati (7.5 FTEs), and University of Wisconsin (7.8 FTEs). One of the top performers was the Mayo Clinic in Minnesota, which uses fewer than 9 physicians per 1,000 patients on average, in the six months before death, compared to the most resource-heavy institution, NYU Medical Center, which used 28 physicians per 1,000 terminally ill patients.

Nearly all of the efficient centers are large, multi-specialty practices integrated with hospitals.

Goodman concludes that using the Mayo Clinic ratio as a benchmark, there could be an excess of nearly 50,000 doctors by 2020. Using the NYU doctor-patient ratio, on the other hand, would leave us 44,000 doctors in the hole.

Goodman notes that the research is consistent with prior CECS studies that showed that in high doctor-patient-ratio parts of the country, such as Miami, people with severe chronic illnesses get more physician care in visits, hospitalizations, and procedures than people who live in low-ratio areas like Minneapolis. Yet, the additional interventions yield no benefit. The elderly in Miami are subject to more echocardiograms and mechanical ventilation, leading to more hospitalizations, intensive care unit stays, specialist visits, and diagnostic tests, Goodman notes. Yet, the Floridians don’t live longer or report more satisfaction with their care than the elderly in Minneapolis. And previous studies have shown no discrepancy in the quality of care.

“If all medical practices adopted the style and resource use of the efficient providers, patient care would cost less and patients would be less subject to unnecessary tests and treatments that could do more harm than good,” says Goodman.

Rather than training more doctors than we need, he says we should focus on better coordinating care. He also agrees with those who say resources should go toward improving efforts to prevent illness and manage chronic ailments like diabetes and heart disease. And he concurs with the geriatricians who advocate for investing in geriatrics as an academic specialty.

“The fact is,” Goodman notes, “the projected doctor shortage assumes that the health care system in the future is going to be the same as the one today, that it will have the same levels of efficiency, the same financing, and the same organization. I think that anyone who looks at today’s health care system will recognize that not only is change inevitable, it is necessary.”

Vexing but not impossible
Today’s elderly are not prepared for longevity, and societies are not prepared for today’s elderly, says ILC-USA’s Butler. There are no effective pension systems yet, there is no solution to Alzheimer’s disease, older people have little social status, and there is no infrastructure to support caregivers.

“A lot of the issues we face ultimately are solvable,” he says. “Unfortunately, we have not yet gotten people to fully realize what we are going to have to deal with.”

Copyright 2006 Harvard Medical International