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Summer/Fall 2008 Vol. 8 No. 2

Table of Contents

Š A Looming Health Bust

Influx of Older Patients Could Overwhelm Health System


As millions of baby boomers enter their golden years, a huge wave of older patients, who by nature have more complex health conditions and needs, will place significantly more pressure on the U.S. health care system over the next few decades. This impending age shift in the nation's patient population comes at a time when the health system is woefully unprepared to meet the needs of so many older patients.

Already there is a dearth of health professionals who specialize in geriatric care, and most clinicians receive little if any training in even the common conditions associated with aging, such as frailty and sensory impairment. With turnover rates among nursing assistants and personal care aides as high as 90 percent annually, many long-term and home care services can offer patients little staffing consistency.

But it's not too late to make needed changes in how health care is delivered and financed to ensure that older Americans get the quality care they need to live robustly and independently for as many years possible, says a new report from the Institute of Medicine. The report outlines a three-prong solution that includes boosting the recruitment and retention of geriatric specialists and caregivers, enhancing the abilities of all care providers to respond to older patients' social and medical needs, and making fundamental changes in the way health care is delivered.

Geriatrics languishes behind other specialties in the number of providers it attracts. Currently there is just one geriatrician for every 2,500 older Americans and less than 1 percent of nurses and pharmacists pursue geriatric specialties. Low pay is a big reason. A geriatrician earned an annual salary of $163,000 compared with $175,000 for a general internist in 2005, and some specialties offer $300,000 a year or more. To mitigate this disparity, Medicare -- the principal payer for medical care provided to older patients -- should reimburse more for services when they are delivered by geriatric specialists, the report urges. Similarly, states need to boost pay for nursing assistants and other direct-care workers whose median wages of $9.95 per hour fall below the poverty level in some regions.

Geriatric specialists are crucial not only for treating patients with complex health problems but also for training other health care providers to handle the conditions associated with aging. Virtually all health care providers treat older patients to some extent during their careers -- and likely will do so even more frequently given that one in five Americans will be 65 or older by 2030. The report calls for competency in basic geriatric care as a requirement for health care workers to get and maintain their licenses and certifications.

Simply having more and better trained health care providers isn't enough, however. The way care is currently delivered -- with a focus on treating acute symptoms rather than management of chronic conditions, and providers working solo rather than as teams -- needs to change as well, the report says. Health plans need to reimburse providers for services not currently covered, such as educating patients on managing their chronic problems. Also, given the shortage of health care workers, it's time to consider expanding the roles and responsibilities of providers. For example, if a certified nursing assistant is able to administer certain medications, a professional nurse would have more time to concentrate on more complex patient needs.

If current trends continue unchanged, the United States will fail to ensure that high-quality care is available to every older American, the report says. The dramatic demographic shifts in the patient population demand similar transformations in the health care work force and models of care delivery.   -- Christine Stencel

Retooling for an Aging America: Building the Health Care Workforce. Committee on the Future Health Care Workforce for Older Americans, Board on Health Care Services, Institute of Medicine (2008, 316 pp.; ISBN 0-309-11587-6; available from the National Academies Press, tel. 1-800-624-6242; $29.95 plus $4.50 shipping for single copies).

The committee was chaired by John W. Rowe, professor of health policy and management, Mailman School of Public Health, Columbia University, New York City. The study was funded by the John A. Hartford Foundation, Atlantic Philanthropies, Josiah Macy Jr. Foundation, Robert Wood Johnson Foundation, Retirement Research Foundation, California Endowment, Archstone Foundation, AARP, Fan Fox and Leslie R. Samuels Foundation, and Commonwealth Fund.

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Copyright 2008 by the National Academy of Sciences