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The Future Of Health Care Delivery In An Aging Society Jonathan M Evans MD.

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Presentation on theme: "The Future Of Health Care Delivery In An Aging Society Jonathan M Evans MD."— Presentation transcript:

1 The Future Of Health Care Delivery In An Aging Society Jonathan M Evans MD

2 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

3 Outline Part 1 aging society Part 1 aging society Part 2 current state of health care, govt Part 2 current state of health care, govt Part 3 Future of health Care Part 3 Future of health Care

4 Part 1 Aging Society

5 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

6 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

7 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?

8 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?

9 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

10 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

11 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!)

12 Part 2: Current State of Health Care, Gov’t

13 Government (Congress) inaction as action what does that mean?

14 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

15 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)

16 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

17 Will the number of nursing homes (nursing home beds) increase in the future? why/why not? what kind? What will they look like?

18 What drove historical growth in nursing homes in past?

19 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)

20 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?

21 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.

22 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 ”

23 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)

24 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

25 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

26 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

27 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 20 th century: by body part Early 20 th century: by body part Late 20 th century to now: by site of care

28 “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

29 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”

30 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

31 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?

32 Workforce issues: 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

33 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

34 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

35 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)

36 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?

37 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

38 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

39 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)

40 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

41 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

42 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


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