Defining Challenges

A disease-based, doctor-centered medicine served us well for the first half of the 20th century, but economic pressures and a changing population are revealing its shortcomings.

What the ‘Silver Tsunami’ Means for U.S. Health Care: An Interview with Thomas Gill of the Yale Center on Aging

Dr. Thomas Gill

Dr. Thomas Gill

America’s population is growing older. It is estimated that by 2050, people over 65 will represent more than 20 percent of the population, up from 15 percent today. That shift may not sound significant, but it represents about 40 million additional Medicare-age patients flooding the already beleaguered U.S. healthcare system. This flood, the so-called ‘silver tsunami’ will be driven partially by advances in medicine that are helping people live longer, but also by the Baby Boomers, people born during the population spike after World II who are reaching old age.

This groundswell of elderly patients has raised concerns. As we age, we become more vulnerable to chronic conditions, which can accumulate over time. The disease-centric style of Western medicine has proven inadequate to address these conditions. Meanwhile, the number of geriatricians has declined, leaving many to wonder who will care for this aging population?

Dr. Thomas Gill, Director of the Program on Aging at Yale University and a recognized authority on the epidemiology and prevention of disability among older persons, tells us what this ‘silver tsunami’ means for American healthcare and how people can take control of their health as they reach old age.

Q: As our population ages, how will it change the type and frequency of illnesses that doctors are responsible for treating?

I think there are at least two important areas. First, doctors will be dealing more frequently with the management of multiple chronic conditions. In what has been the standard of care, doctors often focus on individual diseases. That type of care will become out of date and it could be harmful because the management of one chronic condition could worsen another. There’s a movement in the field that clinical decision making in an aging population should be predicated on attaining individual goals of patients and identifying modifiable factors whether they’re biologic or non-biologic. Rather than focusing narrowly on individual diseases, a broader approach is needed. As opposed to a younger population, where a patient might present with a single condition like community-acquired pneumonia which responds quite favorably to antibiotics, things are a lot more complex in an aging population where patients can have a series of chronic conditions.

Participants in On Lok’s PACE program.

Seniors at On Lok Lifeways ‘daycare’ center.

A second important area, in terms of an aging population, is Alzheimer’s disease. It doubles in prevalence every five years after age 60, when it is present in about two percent of patients. By the time someone gets to age 85, they face a one out of three chance of having Alzheimer’s disease, and some surveys suggest a figure as high as fifty percent. As the population continues to age, the number of patients who have Alzheimer’s disease or other types of dementia will increase substantially. And these disorders tend to require a lot of care. There’s a very important ratio that’s often discussed–it’s called the old-oldest support ratio. The numerator includes the number of the caregivers, who are typically about 50 to 74 years old, while the denominator includes the persons who need the care, who are usually those 85 and older. This ratio was a very healthy 31 back in 1970. It was 10 in 2010. And its projected to be 4 in 2050. This means that there will be fewer persons available to provide care for an aging society.

Q: What changed?

The denominator is getting larger. In fact, the fastest growing segment of the population are those who are 85 and older. And those are the ones who will have the larger number of chronic conditions because they accumulate over time and with age. They’re going to have the highest rates of Alzheimer’s disease and other types of dementia and have the highest care needs. The 50 to 74 years olds, that’s going to be the post-Baby Boomers. So you have Baby Boomers in the denominator and the post-Baby Boomers in the numerator and their population is just smaller. You’re going to have fewer caregivers available and its projected to put a tremendous stress on the system. The majority of the care that the “oldest old” currently get outside of institutional settings is informal care from family.

The shrinking oldest-old support ratio is raising a lot of concerns at the highest level in terms of policy and also on the ground–people are asking “Who’s going to be taking care of grandma or grandpa?”. There are ongoing discussions and research about different models of care, and I don’t think we have any easy solutions at this time. Clearly there’s a lot of research and interest in trying to improve active life expectancy. The goal is not necessarily to increase longevity, but to increase independent function until as late in life as possible so that the person only needs hands-on care for a very short period of time prior to their death.

There have been some successes over the past few decades. In particular, we are managing some chronic conditions more effectively, such as high blood pressure, diabetes, and coronary artery disease. For other conditions such as Alzheimer’s disease, we haven’t been as successful, and that is why the Federal government is investing more and more resources to address Alzheimer’s disease. In fact, I believe it’s one of the few areas in the National Institutes of Health budget, at least the National Institute on Aging, that’s increasing this coming year, while everything else is flat or decreasing.

Q: Is our healthcare system adequately prepared to deal with an aging population? If not, how does it need to change?

I think it’s going to be a great challenge. The demographic figures raise a lot of concern, both in terms of the supports that are available, the costs for hands-on care and the number of clinicians who are trained in geriatrics, which has been declining. Fee-for-service medicine encourages doing more procedures, many of which are costly. Patients are often treated for individual diseases, and care is often organ-based–cardiologists are assigned the heart, pulmonologists the lungs, etc. So you have this kind of balkanization of the patient, which generally increases costs. In addition, different specialists often work at cross-purposes with one another. Treatments for the heart can make treatments for the lung worse and vice-versa.

So different models of care are being developed and tested in an attempt to improve outcomes. Older persons are at high risk for poor outcomes, especially those who are physically or cognitively frail. Communication between clinicians in the hospital and those outside the hospital is sometimes poor, and patients are often re-admitted to the hospital within a month after discharge. Thirty-day readmission is now a quality indicator and health systems are getting penalized by Medicare if their rate is above a certain figure. So there are some attempts to improve what you might call more “holistic care”, but we have a lot of work ahead of us. One of the defining features in geriatrics is team-based care, interdisciplinary care that includes not just physicians but nurses, social workers, pharmacists and physical and occupational therapists.

Q: One team-based model that has a lot of support is the “Patient-Centered Medical Home” model. Do you think that is an effective model for dealing with this aging population?

That’s a model that’s been tested at a relatively small number of sites across the country, and the evidence is highly supportive. The question is whether this model is scalable? Many of these new models of care are supported through demonstration projects that are funded by the Centers for Medicare and Medicaid Services. If successful, the model could be added as a Medicare benefit. These models often require some investment at the start, with the hope that there may be some savings over time, along with improved quality of care. Medicare was originally designed as a fee for service program, and it still has many of these elements, which aren’t most conducive to providing high-quality care to an aging population.

Q: The vast majority of Americans do not want to go to a nursing home. Why?

When older persons are asked “What’s your number one priority?”, they almost always respond that it’s to maintain their independence. They want to stay in their own homes and not have to rely on others. However, to accomplish their larger goal of staying in their own home, older persons are often willing to rely on others. This can be accomplished with support from informal and paid caregivers.

The quality of care in nursing homes has improved tremendously over the last 20 years, and a large proportion of older persons will spend some time in a nursing home during the course of their life, often for rehabilitation after a hospitalization. The number of long-term nursing home beds is constrained. Because Medicaid is the primary funder of long-term nursing home care, the states have a financial incentive to keep older persons in their own home. So, they may support expanded home care programs that provide home health aides and other services in the home. These types of program are often cost-effective relative to very expensive nursing home care, which in some states will average $6000 to $8000 per month.

Q: Where do those high costs come from?

There are a lot of fixed costs in running a nursing home, which provide ongoing medical care, custodial care, and lodging. Nursing homes are highly regulated and they have to provide access to a panoply of different clinicians, including nursing and rehabilitation specialists.

Q: What makes for a successful, healthy living situation for elderly, frail people? Is there any particular recipe that works?

The strongest evidence for preventing frailty and disability is physical activity. Recent evidence from the LIFE (Lifestyle Interventions and Independence for Elders) Study demonstrated that a long-term physical activity program can reduce the likelihood of developing major disability in mobility among sedentary older persons with functional limitations. Walking was the primary mode of physical activity, with a goal of 30 minutes a day 5 days a week.

Q: So it follows the idea that “if you don’t use it, you lose it”?

Absolutely. Unfortunately, our society encourages sedentary behaviors–the average adult spends several hours a day watching television and basically all you have to do is walk outside to your car to get from one place to another. That doesn’t really promote physical activity. Sedentary behaviors can often contribute to obesity, which is becoming more common among older persons. With obesity, there’s more fat and less muscle which leads to an assortment of complications including frailty, disability and ultimately dependence and nursing home admission.

Q: What qualities do health care professionals need to care for older, frail people? Do doctors need to think differently when treating elderly patients?

There’s a very important focus on the whole patient as opposed to individual organs and diseases. It’s also important to try to solicit values and goals of patients in this age group. With aging, persons become less alike. There’s a saying that “If you’ve seen one 75 year old, you’ve seen one 75 year old.” Given the tremendous heterogeneity observed among older persons, medical management should be tailored to one’s specific circumstances. This requires making decisions based on the patient’s values, preferences and goals. Prognosis is another important consideration. For example, if life expectancy is only 5 years, screening for colon cancer is not going to offer much benefit because you need live about 10 years to accrue any benefits. For many older persons, particularly those who are frail or have limited life expectancy, “less is more”, meaning that aggressive care often does not improve important outcomes. Older persons are more susceptible to having complications from many types of tests and treatments.

Q: Is the heterogeneity in an older population driven by chronic disease?

The occurrence of chronic diseases is definitely an important consideration. Another is genetics. If you have parents and grandparents who lived into their 80s and beyond in relatively good health, you are likely to inherit some of these same traits. Practicing health behaviors, such as not smoking, being physically active, eating well, is also very important in terms of aging successfully.

Q: How should an individual that’s part of the coming “tsunami” approach their own healthcare? How can they get the most from their providers?

It’s advisable to be prepared. For each doctor appointment, they should have a clear agenda. Write down questions in advance. If needed, come with a caregiver or another loved one who could either help frame those questions or perhaps ensure the communication between the physician and the patient is effective. Older patients may have sensory impairments or cognitive impairments that make effective communication with the doctor difficult. So having someone else accompany them to clinic may be useful. It’s important that the doctors understand your priorities and goals of care. If specific tests or treatments are recommended, ask for an explanation. If needed, get a second opinion–particularly for decisions that might necessitate expensive testing or treatments that have potential adverse effects.

Q: The number of doctors working in geriatrics has decreased steadily over the years, which doesn’t bode well for an aging population. Do you see this as a cause for concern and what can be done about it?

The relative paucity of geriatrically-trained clinicians is a great concern. The current payment system rewards procedurally-oriented disciplines and encourages more expensive care that is often fragmented. The salaries of these procedurally-oriented disciplines, such as cardiology, interventional radiology and dermatology, are usually much higher than those for geriatricians.

It’s interesting that studies of new medical students have found that geriatrics is one of the most popular disciplines. By the end of medical school, however, it’s one of the least popular. One reason is that the geriatric training often focuses on the sickest, most debilitated patients and provides relatively little exposure to the large majority of older persons who are relatively healthy. Also, medical school is very expensive and medical students often acquire a lot of debt. This makes a high-paying discipline much more attractive. We need incentives for young physicians to pursue geriatrics like loan forgiveness and higher payment for non-procedurally oriented care, such as care coordination.

Q: Are there other countries that are doing this better?

The fee-for-service model in the US is the exception rather than the rule. In Europe, a larger proportion of physicians practice primary care and geriatrics in a system that provides universal health care. Also, there are typically more constraints on the provision of expensive procedurally-oriented medical care and the difference in salaries between subspecialists and primary care physicians/geriatrics is much smaller than in the US.

Q: What can geriatricians teach doctors working in other areas of medicine?

Because the number of geriatricians is relatively small, it is important that they play an role in medical education and training. This training should occur not only in the hospital, but also in other sites of care such as nursing homes, assisted living communities, home care, and outpatient practices. Geriatricians can educate other physicians on how to effectively operate as a member of a interdisciplinary team. Geriatricians can also instill the need to practice more patient-centered, goal-oriented care. A one-size fits all approach just doesn’t work in geriatrics. Finally, geriatricians can educate other physicians on how to effectively recognize and manage important geriatric syndromes such as falls, confusion, incontinence, polypharmacy and disability.

Q: It sounds like even if more people don’t enter geriatrics, they’ll be working in the field by default because of the way the population demographics are changing.

It’s clearly of great importance to have clinicians in other disciplines provide effective high-quality care to older persons because there’s never going to be enough geriatricians. As the Baby Boomers age, we can hope that they might exert some pressure on policy makers to elevate the importance of geriatrics, especially if their needs are not being met very well. An activated patient can be a very effective in making progress in many of these areas.

Finding Solutions

With chronic disease on the rise, U.S. health care costs skyrocketing and the old model of medicine failing to provided solutions, many are calling for a 'patient-centered' approach to health care.