The Future Of Health Care Delivery In The Future Of Health Care Delivery In An Aging SocietyAn Aging Society

Jonathan M Evans MDJonathan M Evans MD

GoalsGoals

Discuss basic facts and assumptions, current Discuss basic facts and assumptions, current environment, status of gov’t, economy, environment, status of gov’t, economy, healthcare, workforcehealthcare, workforce

Imagine/ Predict potential/likely/desired/feared Imagine/ Predict potential/likely/desired/feared change as population ageschange as population ages

Challenge your own assumptions, conventional Challenge your own assumptions, conventional wisdomwisdom

Talk about what you want and need for yourself, Talk about what you want and need for yourself, parents, childrenparents, children

OutlineOutline

Part 1 aging societyPart 1 aging society

Part 2 current state of health care, govtPart 2 current state of health care, govt

Part 3 Future of health Care Part 3 Future of health Care

Part 1 Aging SocietyPart 1 Aging Society

Aging World (Not just West)Aging World (Not just West)

UnprecedentedUnprecedented– More people in world alive today aged 65 and More people in world alive today aged 65 and

older than all who ever made it to that age in older than all who ever made it to that age in history of world before now !history of world before now !

– (no prior experience to guide future decisions)(no prior experience to guide future decisions)– Lower birth rates, longer survival Lower birth rates, longer survival

Following generation (gen x)smallerFollowing generation (gen x)smaller

Subsequent generation (gen y) biggerSubsequent generation (gen y) bigger– Age wave, not age cliffAge wave, not age cliff

Unprecedented Aging of World Has the Unprecedented Aging of World Has the Potential to Affect Everyone, EverythingPotential to Affect Everyone, Everything

The experience of being alive will change for everyoneThe experience of being alive will change for everyone

Economic, geopolitical, social, psychological, legal, health/ Economic, geopolitical, social, psychological, legal, health/ health care, culture, ethics impacts will be widely felthealth care, culture, ethics impacts will be widely felt

Disproportionate effects Disproportionate effects

– Rural/vs urbanRural/vs urban

– China ‘one child’ policyChina ‘one child’ policy

What if your kids cant take care of you? What if What if your kids cant take care of you? What if nobody’s kids can? What if taking care of you is all nobody’s kids can? What if taking care of you is all they do?they do?

– Japan, Italy baby ‘bust’ post WWII. Economic, social Japan, Italy baby ‘bust’ post WWII. Economic, social impacts nowimpacts now

Crossing the streetCrossing the street

Overall walking speed slows with normal agingOverall walking speed slows with normal aging

Time interval to cross the street at a green light Time interval to cross the street at a green light is too short for many healthy seniorsis too short for many healthy seniors

In Scandinavia, red light interval was changed In Scandinavia, red light interval was changed in order to accommodate proportionately older in order to accommodate proportionately older societysociety

What would effect of that intervention (or lack What would effect of that intervention (or lack thereof) be in this country?thereof) be in this country?

Throughout a persons lifetime, Throughout a persons lifetime, individualindividual needs, goals, priorities changeneeds, goals, priorities change

Why?Why?

How? How? – Does what you buy at the grocery store change? Does what you buy at the grocery store change?

Your clothing? The movies you see? The amount Your clothing? The movies you see? The amount you spend on health care?you spend on health care?

– How/ why might seniors vote differently for school How/ why might seniors vote differently for school bond referendum or gas tax to pay for highways?bond referendum or gas tax to pay for highways?

– Are people at age 90 more likely to buy or sell real Are people at age 90 more likely to buy or sell real estate?estate?

People within a society/community are People within a society/community are connected/ connected/ interdependentinterdependent in some ways even if in some ways even if

they donthey don’’t want to bet want to be

Shared resources, public worksShared resources, public works

Consumer economy depends upon others Consumer economy depends upon others spending moneyspending money

Aging society affects everyone at all agesAging society affects everyone at all ages

As a society ages, need, goals, priorities, As a society ages, need, goals, priorities, preferences (abilities) changepreferences (abilities) change

Cumulative effects of many individuals aging at once Cumulative effects of many individuals aging at once (biological , economic effects)(biological , economic effects)

Cohort effects (i.e. baby boomer culture, “blue hair’ example) Cohort effects (i.e. baby boomer culture, “blue hair’ example) in addition to aging effectsin addition to aging effects

Collective changes in consumer spending will have huge Collective changes in consumer spending will have huge economic impactseconomic impacts

Impact of proportionately fewer younger people on economic Impact of proportionately fewer younger people on economic activity income tax revenues, fewer caregiversactivity income tax revenues, fewer caregivers

Mismatches between needs and resources (infrastructure slow Mismatches between needs and resources (infrastructure slow expensive to changeexpensive to change

– Status quo always resists changeStatus quo always resists change

Basic economic principles impacted by Basic economic principles impacted by changing demographic changing demographic

Size of economy affected by retirement rateSize of economy affected by retirement rate

Supply/demand balance re housing, cars, services, etcSupply/demand balance re housing, cars, services, etc

What would happen if many older workers couldnWhat would happen if many older workers couldn’’t afford to t afford to retire . . . . . (they cant!)retire . . . . . (they cant!)

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

Government (Congress) Government (Congress) inaction as actioninaction as action

what does that mean?what does that mean?

Government InactionGovernment Inaction

Passing no laws means maintaining status quoPassing no laws means maintaining status quo

Means No new regs, programs or increased funding that Means No new regs, programs or increased funding that requires congressional action except in response to perceived requires congressional action except in response to perceived new crisis (one time funding ie VA)new crisis (one time funding ie VA)

– Cultural aversion to raising taxes at all levels of gov’tCultural aversion to raising taxes at all levels of gov’t

– Expect no significant increase in gov’t spending overallExpect no significant increase in gov’t spending overall

Competing priorities- who decides?Competing priorities- who decides?

– Voters routinely act against their own self interestsVoters routinely act against their own self interests

– Politicians never doPoliticians never do

Legislative InactionLegislative Inaction

Administrative actions are/will be taken within Administrative actions are/will be taken within budgetary limitsbudgetary limits

Changing interpretation or enforcement of Changing interpretation or enforcement of rules, not regs themselves (often in response to rules, not regs themselves (often in response to legislative pressure)legislative pressure)

Competition within programs (i,.e Medicaid: Competition within programs (i,.e Medicaid: NH seniors vs children)NH seniors vs children)

Education tends to be static Education tends to be static

Apprenticeship tradition in health careApprenticeship tradition in health care

people teach what they were taught some time people teach what they were taught some time ago (biases, outdated)ago (biases, outdated)

Medical nursing training is something that Medical nursing training is something that happened, not something that continues on happened, not something that continues on throughout a careerthroughout a career

Applies to admistration as wellApplies to admistration as well

Exclusive culture, resists changeExclusive culture, resists change

Will the number of nursing homes (nursing Will the number of nursing homes (nursing home beds) increase in the future?home beds) increase in the future?

why/why not?why/why not?

what kind?what kind?

What will they look like?What will they look like?

What drove historical growth in What drove historical growth in nursing homes in past?nursing homes in past?

What drove historical growth in nursing What drove historical growth in nursing homes in past?homes in past?

Answer: Government spendingAnswer: Government spending

1960s to 1990s: Medicaid 1960s to 1990s: Medicaid Medicaid = Long-term Care insurance for most Medicaid = Long-term Care insurance for most people people

1960s War On Poverty 1960s War On Poverty

1990s to Now: Medicare Part A 1990s to Now: Medicare Part A –DRG PPS for HospitalsDRG PPS for Hospitals–Part A payment for skilled care (SNFs)Part A payment for skilled care (SNFs)

Will There Be More Nursing Homes?Will There Be More Nursing Homes?

Form follows FinanceForm follows Finance

Private investment- Investment decisions Private investment- Investment decisions based on current/near term rate of return, based on current/near term rate of return, borrowing costsborrowing costs

Permission to build required by states (CON) Permission to build required by states (CON) based upon current, not future need (Why?)based upon current, not future need (Why?)

Is that what you want for you?Is that what you want for you?

SNF Transformation in NHsSNF Transformation in NHs

Competing forces: Home-like environment/Culture Change Competing forces: Home-like environment/Culture Change movement vs. SNFs wanting to be, look like ICUsmovement vs. SNFs wanting to be, look like ICUs

Most NHs built for a different business (LTC) for a different Most NHs built for a different business (LTC) for a different market in a a different place than SNF business.market in a a different place than SNF business.

Many NHs will not succeed in transforming to SNF. There Many NHs will not succeed in transforming to SNF. There will be closures, disruptions, esp. in rural areas.will be closures, disruptions, esp. in rural areas.

Current Problems with US Healthcare Current Problems with US Healthcare ‘System’‘System’

Health care quality (whatever that is)Health care quality (whatever that is)

Cost of (health) careCost of (health) care

Access to careAccess to care

These are all interrelated, in various waysThese are all interrelated, in various ways

– C Everett Koop, Former Surgeon General:C Everett Koop, Former Surgeon General:– “ “You can have any 2 out of three, but you cant have all 3 You can have any 2 out of three, but you cant have all 3

at onceat once””

Quality/Quality/Cost/AccessCost/Access

We have serious, systematic quality of care problems We have serious, systematic quality of care problems

– Including serious problems caused by care Including serious problems caused by care fragmentation/disruptionfragmentation/disruption

We have serious, systematic access to care problemsWe have serious, systematic access to care problems

Unsustainable cost of care, however is what is really driving Unsustainable cost of care, however is what is really driving the conversation and all of the decisionsthe conversation and all of the decisions

– (Quality problems, access problems also drive up costs)(Quality problems, access problems also drive up costs)

Major, ongoing Change in Care delivery Major, ongoing Change in Care delivery for Acutely Ill Patientsfor Acutely Ill Patients

Why?Why?

Reactive, not proactiveReactive, not proactive

Not thoughtfully planned, not coordinatedNot thoughtfully planned, not coordinated

Displacement of patients (and practitioners)Displacement of patients (and practitioners)

Enormous, rapid dislocation of sick, complex patients from Enormous, rapid dislocation of sick, complex patients from hospitals to other settings driven by changes in hospital and hospitals to other settings driven by changes in hospital and LTC financing (driven by hospital and LTC cost, driven by . . . LTC financing (driven by hospital and LTC cost, driven by . . . .).)

Rapid relocation of patients and( there needs) has not been Rapid relocation of patients and( there needs) has not been accompanied by the same rapid relocation of resources to accompanied by the same rapid relocation of resources to identify, meet those needsidentify, meet those needs

Cost of CareCost of Care

1/5 of GDP: That1/5 of GDP: That’’s not healthy!s not healthy!

Not every politician cares about health care quality or even Not every politician cares about health care quality or even believes there is a problembelieves there is a problem

They all care about the cost- it affects everything else they care They all care about the cost- it affects everything else they care aboutabout

Promise of higher quality at higher cost (you get what you pay for) Promise of higher quality at higher cost (you get what you pay for) was never realizedwas never realized

Not a problem we can buy our way out ofNot a problem we can buy our way out of– The more we do, the worse we do (why?)The more we do, the worse we do (why?)

We are so desperate to fix these problems that we are trying to fix We are so desperate to fix these problems that we are trying to fix things without really fully understanding the nature, and causes of things without really fully understanding the nature, and causes of the problemsthe problems

Quality/Cost/AccessQuality/Cost/Access

Medical care is inherently dangerousMedical care is inherently dangerous

– Primum non nocerum – HippocratesPrimum non nocerum – Hippocrates

– The urge to do something is often irresistible The urge to do something is often irresistible

(physician heal thyself)(physician heal thyself)

Overtly and systematically limiting care (“rationing”) is Overtly and systematically limiting care (“rationing”) is unacceptably un-american unacceptably un-american

Value proposition: value= quality divided by costValue proposition: value= quality divided by cost

Current value proposition = ripoffCurrent value proposition = ripoff

Lower costs by penalizing poor quality Lower costs by penalizing poor quality

Blame providersBlame providers

Quality Problems/WhyQuality Problems/Why

Health care delivery system that we have was developed for Health care delivery system that we have was developed for the providers, not the patients (we have today) in mindthe providers, not the patients (we have today) in mind

– Complaint based systemComplaint based system

– ““Parking” exampleParking” example

Needing care makes it harder to get itNeeding care makes it harder to get it

Changing health, lifeChanging health, life

– System built for acute care of a single problemSystem built for acute care of a single problem

– Fragmentation of careFragmentation of care

Early 20Early 20thth century: by body part century: by body part

Late 20Late 20thth century to now: by site of care century to now: by site of care

““Incentives are wrong”Incentives are wrong”Providers and practitioners cant charge more for higher qualityProviders and practitioners cant charge more for higher quality

Less your doctor knows, care, or thinks, more they fear,Less your doctor knows, care, or thinks, more they fear,– the worse the quality of care you receivethe worse the quality of care you receive– The more it costs you and everyone elseThe more it costs you and everyone else– Medical education has shifted away from clinical skills, interpersonal skills Medical education has shifted away from clinical skills, interpersonal skills

and critical thinking to technology managementand critical thinking to technology management– Medical care delivery has made a similar shiftMedical care delivery has made a similar shift

Do more but donDo more but don’’t get better resultst get better results

Shift in favor of ‘pay for performance’Shift in favor of ‘pay for performance’– Something that providers and practitioners have long asked for and are now Something that providers and practitioners have long asked for and are now

afraid ofafraid of

Fundamental assumption that money will solve the problem, whatever it isFundamental assumption that money will solve the problem, whatever it is

Fundamentally, we have to change what people know, care, think, what they fear . Fundamentally, we have to change what people know, care, think, what they fear . . . . That’s a very tall order. . . That’s a very tall order

Am I My Brother’s Keeper?Am I My Brother’s Keeper?

Our society is tornOur society is torn

Ambivalence toward others, esp. strangers makes cogent health Ambivalence toward others, esp. strangers makes cogent health care policy impossiblecare policy impossible

Most people want government to do more for them but donMost people want government to do more for them but don’’t t want to/ cant afford to pay morewant to/ cant afford to pay more

Fear of government intrusion in personal decisions (esp. Fear of government intrusion in personal decisions (esp. rationing care)rationing care)

Huge, entrenched monied interests (insurance industry, hospitals, Huge, entrenched monied interests (insurance industry, hospitals, pharmaceutical lobby) also represent many jobs at stakepharmaceutical lobby) also represent many jobs at stake

Ignorance about role govt plays: GOVERNMENT KEEP YOUR Ignorance about role govt plays: GOVERNMENT KEEP YOUR HANDS OFF MY MEDICARE”HANDS OFF MY MEDICARE”

We Can’t Buy Our Way OutWe Can’t Buy Our Way Out

There are not, will not be enough formal (i.e. licensed, paid) There are not, will not be enough formal (i.e. licensed, paid) caregiverscaregivers

More caregiving by family members, aged spouses, peers, More caregiving by family members, aged spouses, peers, neighbors, friends/ informal networks in all settings, neighbors, friends/ informal networks in all settings, even even hospitalshospitals

Could have serious direct and indirect economic implications Could have serious direct and indirect economic implications for everyonefor everyone

We Can’t Buy Our Way OutWe Can’t Buy Our Way Out

What will happen when every hospitalized elderly patient What will happen when every hospitalized elderly patient receives the exact same care as young and middle aged receives the exact same care as young and middle aged patients, and there are a lot more of them?patients, and there are a lot more of them?

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

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 Other Healthcare infrastructure issuesissues

Pharmacists, pharmacies esp LTCPharmacists, pharmacies esp LTCAccess to lab testing, imaging, records Access to lab testing, imaging, records NHs retrofitting to SNFsNHs retrofitting to SNFsDisplacement from NH to ALF/home = shift Displacement from NH to ALF/home = shift

of burden from public to privateof burden from public to private

Bad health, bad care ultimately cost Bad health, bad care ultimately cost society more society more

Drain on economyDrain on economyNegative effects on civil societyNegative effects on civil societyThe question is who bears the costs, who reaps The question is who bears the costs, who reaps

rewards?rewards?– (ex, Cigarette manufacturers, HMOs)(ex, Cigarette manufacturers, HMOs)

Future of Health Care in an Aging Future of Health Care in an Aging Society: Society:

How might population aging be How might population aging be goodgood for our for our society in general, and health care in society in general, and health care in particular?particular?

How might population aging be How might population aging be bad?bad?

How Might Population Aging Be Good?How Might Population Aging Be Good? An amazing human resource of healthy seniors with collected An amazing human resource of healthy seniors with collected

wisdomwisdom Intergenerational benefits, pooled family human and economic Intergenerational benefits, pooled family human and economic

resources to help with child rearing, education, may provide resources to help with child rearing, education, may provide economic, cultural booneconomic, cultural boon

Greater interdependence may improve civil society, community ethosGreater interdependence may improve civil society, community ethos Many industries will benefit, population will shiftMany industries will benefit, population will shift Volunteer army of seniors can benefit all, support public institutionsVolunteer army of seniors can benefit all, support public institutions Ability to provide high quality senior care will have positive effects Ability to provide high quality senior care will have positive effects

on care in generalon care in general Seniors may have positive impact on definition of health care qualitySeniors may have positive impact on definition of health care quality

Good geriatric medicine a model for all Good geriatric medicine a model for all care for all ages, all health care training care for all ages, all health care training

Prescribing based on age, physiologyPrescribing based on age, physiology Patient, family centered goals of carePatient, family centered goals of care Understanding of systems and processes of care deliveryUnderstanding of systems and processes of care delivery Advance care planning and communicationAdvance care planning and communication Interprofessional teamworkInterprofessional teamwork Advocacy for patients, familiesAdvocacy for patients, families Improved emphasis on communication, care transitions Improved emphasis on communication, care transitions

These are advanced skills, however that require prerequisite These are advanced skills, however that require prerequisite knowledge, as well as appropriate attitudesknowledge, as well as appropriate attitudes

How Might Population Aging be Bad?How Might Population Aging be Bad? Bigotry: In a culture of scarcity, ageism may worsenBigotry: In a culture of scarcity, ageism may worsen Potential for intergenerational conflict (zero-sum game)Potential for intergenerational conflict (zero-sum game) Greater neglect, abuse of seniors by individuals, by institutionsGreater neglect, abuse of seniors by individuals, by institutions Significant economic disruption, economic contraction could occurSignificant economic disruption, economic contraction could occur

– Fewer workers, smaller tax base, decreased productivity Fewer workers, smaller tax base, decreased productivity

– Many industries will suffer, populations will shift Many industries will suffer, populations will shift Youth unemployment could rise, esp. for unskilled (male) workersYouth unemployment could rise, esp. for unskilled (male) workers Care could be horrible for many seniors, esp. in certain placesCare could be horrible for many seniors, esp. in certain places Current health care quality metrics applied to older patients could make Current health care quality metrics applied to older patients could make

matters worsematters worse Resources needed for care elsewhere could be squandered by ‘upstream’ Resources needed for care elsewhere could be squandered by ‘upstream’

providers providers Immigration policy could have many different effects (good and bad)Immigration policy could have many different effects (good and bad)

Future of Health Care in Aging Society Future of Health Care in Aging Society (Some) Of My Predictions(Some) Of My Predictions

Role of hospitals, other care settings will change furtherRole of hospitals, other care settings will change further Government (Medicare) will be a strong driver of further change Government (Medicare) will be a strong driver of further change Funding for medical, nursing education will change, to trim fat, Funding for medical, nursing education will change, to trim fat,

target spending (elsewhere) for greater public health impacttarget spending (elsewhere) for greater public health impact Many university based teaching hospitals, programs will failMany university based teaching hospitals, programs will fail University based nursing schools, medical schools will face greater University based nursing schools, medical schools will face greater

outside pressureoutside pressure Prestige of hospitals overall will decline, as more baby boomers Prestige of hospitals overall will decline, as more baby boomers

experience hospitals, resources, priorities shift elsewhereexperience hospitals, resources, priorities shift elsewhere

Predictions Cont’dPredictions Cont’d More patients will leave hospitals without a (correct) diagnosisMore patients will leave hospitals without a (correct) diagnosis More will fail to access social services in hospitalMore will fail to access social services in hospital Care will get worse in many settings, then better Care will get worse in many settings, then better Education, certification after ‘formal’ training will have much Education, certification after ‘formal’ training will have much

bigger impact, keep more people in workforcebigger impact, keep more people in workforce Much more consolidation in health care industryMuch more consolidation in health care industry

– May lead to more union-like involvement (union? Or May lead to more union-like involvement (union? Or professional society? For professionals)professional society? For professionals)

Greater involvement by families in direct care will affect regulation, Greater involvement by families in direct care will affect regulation, litigation (Ultimately in positive way), will affect social attitudes litigation (Ultimately in positive way), will affect social attitudes (LGBT, EOL, pain mgmt (LGBT, EOL, pain mgmt

Single payor system may become a reality of necessity (market Single payor system may become a reality of necessity (market failure, cost)failure, cost)

Baby boomers will demand positive change and get someBaby boomers will demand positive change and get some

Summary/ConclusionsSummary/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