The Future Of Health Care Delivery In
An Aging Society
Jonathan M Evans MD
Goals
Discuss basic facts and assumptions, current
environment, status of gov’t, economy,
healthcare, workforce
Imagine/ Predict potential/likely/desired/feared
change as population ages
Challenge your own assumptions,
conventional wisdom
Talk about what you want and need for
yourself, parents, children
Outline
Part 1 aging society
Part 2 current state of health care, govt
Part 3 Future of health Care
Part 1 Aging Society
Aging World (Not just West)
Unprecedented
– More people in world alive today aged 65 and
older than all who ever made it to that age in
history of world before now !
– (no prior experience to guide future decisions)
– Lower birth rates, longer survival
Following generation (gen x)smaller
Subsequent generation (gen y) bigger
– Age wave, not age cliff
Unprecedented Aging of World Has the
Potential to Affect Everyone, Everything
The experience of being alive will change for everyone
Economic, geopolitical, social, psychological, legal, health/
health care, culture, ethics impacts will be widely felt
Disproportionate effects
– Rural/vs urban
– China ‘one child’ policy
What if your kids cant take care of you? What if
nobody’s kids can? What if taking care of you is all they
do?
– Japan, Italy baby ‘bust’ post WWII. Economic, social
impacts now
Crossing the street
Overall walking speed slows with normal
aging
Time interval to cross the street at a green light
is too short for many healthy seniors
In Scandinavia, red light interval was changed
in order to accommodate proportionately older
society
What would effect of that intervention (or lack
thereof) be in this country?
Throughout a persons lifetime, individual
needs, goals, priorities change
Why?
How?
– Does what you buy at the grocery store change?
Your clothing? The movies you see? The amount
you spend on health care?
– How/ why might seniors vote differently for
school bond referendum or gas tax to pay for
highways?
– Are people at age 90 more likely to buy or sell real
estate?
People within a society/community are
connected/ interdependent in some ways even if
they don’t want to be
Shared resources, public works
Consumer economy depends upon others
spending money
Aging society affects everyone at all ages
As a society ages, need, goals, priorities,
preferences (abilities) change
Cumulative effects of many individuals aging at once
(biological , economic effects)
Cohort effects (i.e. baby boomer culture, “blue hair’ example)
in addition to aging effects
Collective changes in consumer spending will have huge
economic impacts
Impact of proportionately fewer younger people on economic
activity income tax revenues, fewer caregivers
Mismatches between needs and resources (infrastructure slow
expensive to change
– Status quo always resists change
Basic economic principles impacted by
changing demographic
Size of economy affected by retirement rate
Supply/demand balance re housing, cars, services, etc
What would happen if many older workers couldn’t afford to
retire . . . . . (they cant!)
Part 2: Current State of Health
Care, Gov’t
Government (Congress)
inaction as action
what does that mean?
Government Inaction
Passing no laws means maintaining status quo
Means No new regs, programs or increased funding that
requires congressional action except in response to perceived
new crisis (one time funding ie VA)
– Cultural aversion to raising taxes at all levels of gov’t
– Expect no significant increase in gov’t spending overall
Competing priorities- who decides?
– Voters routinely act against their own self interests
– Politicians never do
Legislative Inaction
Administrative actions are/will be taken within
budgetary limits
Changing interpretation or enforcement of
rules, not regs themselves (often in response to
legislative pressure)
Competition within programs (i,.e Medicaid:
NH seniors vs children)
Education tends to be static
Apprenticeship tradition in health care
people teach what they were taught some time
ago (biases, outdated)
Medical nursing training is something that
happened, not something that continues on
throughout a career
Applies to admistration as well
Exclusive culture, resists change
Will the number of nursing homes (nursing
home beds) increase in the future?
why/why not?
what kind?
What will they look like?
What drove historical growth in
nursing homes in past?
What drove historical growth in nursing
homes in past?
Answer: Government spending
1960s to 1990s: Medicaid
Medicaid = Long-term Care insurance for most
people
1960s War On Poverty
1990s to Now: Medicare Part A
– DRG PPS for Hospitals
– Part A payment for skilled care (SNFs)
Will There Be More Nursing Homes?
Form follows Finance
Private investment- Investment decisions
based on current/near term rate of return,
borrowing costs
Permission to build required by states (CON)
based upon current, not future need (Why?)
Is that what you want for you?
SNF Transformation in NHs
Competing forces: Home-like environment/Culture Change
movement vs. SNFs wanting to be, look like ICUs
Most NHs built for a different business (LTC) for a different
market in a a different place than SNF business.
Many NHs will not succeed in transforming to SNF. There
will be closures, disruptions, esp. in rural areas.
Current Problems with US Healthcare
‘System’
Health care quality (whatever that is)
Cost of (health) care
Access to care
These are all interrelated, in various ways
– C Everett Koop, Former Surgeon General:
– “You can have any 2 out of three, but you cant have all 3
at once”
Quality/Cost/Access
We have serious, systematic quality of care problems
– Including serious problems caused by care
fragmentation/disruption
We have serious, systematic access to care problems
Unsustainable cost of care, however is what is really driving
the conversation and all of the decisions
– (Quality problems, access problems also drive up costs)
Major, ongoing Change in Care delivery
for Acutely Ill Patients
Why?
Reactive, not proactive
Not thoughtfully planned, not coordinated
Displacement of patients (and practitioners)
Enormous, rapid dislocation of sick, complex patients from
hospitals to other settings driven by changes in hospital and
LTC financing (driven by hospital and LTC cost, driven by . . .
.)
Rapid relocation of patients and( there needs) has not been
accompanied by the same rapid relocation of resources to
identify, meet those needs
Cost of Care
1/5 of GDP: That’s not healthy!
Not every politician cares about health care quality or even
believes there is a problem
They all care about the cost- it affects everything else they care
about
Promise of higher quality at higher cost (you get what you pay
for) was never realized
Not a problem we can buy our way out of
– The more we do, the worse we do (why?)
We are so desperate to fix these problems that we are trying to
fix things without really fully understanding the nature, and
causes of the problems
Quality/Cost/Access
Medical care is inherently dangerous
– Primum non nocerum – Hippocrates
– The urge to do something is often irresistible
(physician heal thyself)
Overtly and systematically limiting care (“rationing”) is
unacceptably un-american
Value proposition: value= quality divided by cost
Current value proposition = ripoff
Lower costs by penalizing poor quality
Blame providers
Quality Problems/Why
Health care delivery system that we have was developed for
the providers, not the patients (we have today) in mind
– Complaint based system
– “Parking” example
Needing care makes it harder to get it
Changing health, life
– System built for acute care of a single problem
– Fragmentation of care
Early 20th century: by body part
Late 20th century to now: by site of care
“Incentives are wrong”
Providers and practitioners cant charge more for higher quality
Less your doctor knows, care, or thinks, more they fear,
– the worse the quality of care you receive
– The more it costs you and everyone else
– Medical education has shifted away from clinical skills, interpersonal
skills and critical thinking to technology management
– Medical care delivery has made a similar shift
Do more but don’t get better results
Shift in favor of ‘pay for performance’
– Something that providers and practitioners have long asked for and are
now afraid of
Fundamental assumption that money will solve the problem, whatever it is
Fundamentally, we have to change what people know, care, think, what
they fear . . . . That’s a very tall order
Am I My Brother’s Keeper?
Our society is torn
Ambivalence toward others, esp. strangers makes cogent
health care policy impossible
Most people want government to do more for them but don’t
want to/ cant afford to pay more
Fear of government intrusion in personal decisions (esp.
rationing care)
Huge, entrenched monied interests (insurance industry,
hospitals, pharmaceutical lobby) also represent many jobs at
stake
Ignorance about role govt plays: GOVERNMENT KEEP
YOUR HANDS OFF MY MEDICARE”
We Can’t Buy Our Way Out
There are not, will not be enough formal (i.e. licensed, paid)
caregivers
More caregiving by family members, aged spouses, peers,
neighbors, friends/ informal networks in all settings, even
hospitals
Could have serious direct and indirect economic implications
for everyone
We Can’t Buy Our Way Out
What will happen when every hospitalized elderly patient
receives the exact same care as young and middle aged
patients, and there are a lot more of them?
Workforce issues: Quantitative:
shortage of caregivers at all levels especially in primary care,
sites outside of hospital
Many barriers to train/ retool/retrain
Low wage workers may become most critical shortage (why?)
Will there be enough caregivers? Who will they be?
Inherent difficulty of increasing productivity among
professionals (all professions, not just health care)
Limits/problems of technology as substitute for people, or to
increase productivity
Workforce Issues: Qualitative
Trained wrong
Negative culture of healthcare: Ageism, attitiudes of doctors,
others towards non-hospital care, towards one another (bigotry
=dislike of the unlike)
Inability of physicians to retool, be fully credentialed in
current postgrad training regime
Difficulty, expense of retooling nurse workforce LPN/RN
Failures of nursing schools, medical schools, residencies to
train people for the jobs that are needed, the jobs they will
have in future
Lack of training re geriatrics esp drug prescribing, care in sites
outside of hospital, interprofessional teamwork, parallel world
Difficulty (impossibility) of retraining teachers
Wrong training sites
Other Healthcare infrastructure
issues
Pharmacists, pharmacies esp LTC
Access to lab testing, imaging, records
NHs retrofitting to SNFs
Displacement from NH to ALF/home = shift
of burden from public to private
Bad health, bad care ultimately cost
society more
Drain on economy
Negative effects on civil society
The question is who bears the costs, who reaps
rewards?
– (ex, Cigarette manufacturers, HMOs)
Future of Health Care in an Aging
Society:
How might population aging be good for our
society in general, and health care in
particular?
How might population aging be bad?
How Might Population Aging Be Good?
An amazing human resource of healthy seniors with collected
wisdom
Intergenerational benefits, pooled family human and economic
resources to help with child rearing, education, may provide
economic, cultural boon
Greater interdependence may improve civil society,
community ethos
Many industries will benefit, population will shift
Volunteer army of seniors can benefit all, support public
institutions
Ability to provide high quality senior care will have positive
effects on care in general
Seniors may have positive impact on definition of health care
quality
Good geriatric medicine a model for all
care for all ages, all health care training
Prescribing based on age, physiology
Patient, family centered goals of care
Understanding of systems and processes of care delivery
Advance care planning and communication
Interprofessional teamwork
Advocacy for patients, families
Improved emphasis on communication, care transitions
These are advanced skills, however that require prerequisite
knowledge, as well as appropriate attitudes
How Might Population Aging be Bad?
Bigotry: In a culture of scarcity, ageism may worsen
Potential for intergenerational conflict (zero-sum game)
Greater neglect, abuse of seniors by individuals, by institutions
Significant economic disruption, economic contraction could occur
– Fewer workers, smaller tax base, decreased productivity
– Many industries will suffer, populations will shift
Youth unemployment could rise, esp. for unskilled (male) workers
Care could be horrible for many seniors, esp. in certain places
Current health care quality metrics applied to older patients could make
matters worse
Resources needed for care elsewhere could be squandered by ‘upstream’
providers
Immigration policy could have many different effects (good and bad)
Future of Health Care in Aging Society
(Some) Of My Predictions
Role of hospitals, other care settings will change further
Government (Medicare) will be a strong driver of further
change
Funding for medical, nursing education will change, to trim
fat, target spending (elsewhere) for greater public health
impact
Many university based teaching hospitals, programs will fail
University based nursing schools, medical schools will face
greater outside pressure
Prestige of hospitals overall will decline, as more baby
boomers experience hospitals, resources, priorities shift
elsewhere
Predictions Cont’d
More patients will leave hospitals without a (correct) diagnosis
More will fail to access social services in hospital
Care will get worse in many settings, then better
Education, certification after ‘formal’ training will have much
bigger impact, keep more people in workforce
Much more consolidation in health care industry
– May lead to more union-like involvement (union? Or
professional society? For professionals)
Greater involvement by families in direct care will affect
regulation, litigation (Ultimately in positive way), will affect
social attitudes (LGBT, EOL, pain mgmt
Single payor system may become a reality of necessity (market
failure, cost)
Baby boomers will demand positive change and get some
Summary/Conclusions
Population aging affects everyone
Aging population could have tremendous positive impact on
humans, and on on improving (senior) care across the
continuum
enormous, unprecedented opportunity to do good
Things likely to get worse before they get better
Traditonal views, attitudes toward health care, settings,
practitioners, family roles will likely change