We have all seen the statistics; America is an aging country. The baby boomer generation is retiring, and families are having fewer and fewer children.
In health care, we often hear about this issue in the context of an inadequate health care workforce. An aging population in conjunction with the ACA has created a quickly growing pool of patients that outpaces the slow growth in the supply of health care providers.
But this narrow discussion fails to recognize the multitude of ways that an aging population strains our health care system. Using an ecological approach, I’d like to share a few anecdotes from the first half of my intern year that give a small glimpse at issues that arise as our population ages.
Health care system
Older patients are the most frequent users of health care; as their population grows, there will be obvious strain on the health care system. But something that is often not discussed is that hospitals are often used as hotels for patients who are not sick enough to be in a hospital but not well enough to live at home.
Many of our older patients are discharged from the hospital to a skilled nursing facility (SNF), but insurance often pays for a maximum of 90-days at SNFs each year. After this stay, if the family does not have resources and the patient becomes too weak to live at home, there are few places for the patient to go.
A few months ago, I had a patient admitted to await placement at a more long-term facility. She spent close to one week in the hospital with no acute need while our case managers worked with her family and insurance company to find a more long-term solution. While this is not rampant, it is frequent enough that I am confident that every one of my co-residents has cared for a similar patient.
This type of disposition problem strains the health care system. It prevents hospitals from caring for patients who need acute care. Furthermore, it clearly illustrates the need for more facilities that meet the needs of this specific population.
Health care providers
As a health care provider, I often feel unprepared to care for my geriatric patients. The evidence-based care we learn about is often applicable to the 40 to 65-year-old patients included in trials. Older patients are often excluded from many studies.
Thus, provision of care to older patients usually requires a more nuanced approach, including a discussion of risks and benefits. Shared decision-making becomes critical. Unfortunately, the way that care is structured in multiple settings allows little time for this crucial task.
I have a handful of octogenarians in my primary care patient panel. At that age, almost every decision involves some element of patient preference. But the way that primary care visits are structured means that it’s nearly impossible to explore all of a patient’s preferences.
This meant that when my 80+ year-old patient wanted to test for prostate cancer and colorectal cancer (and I was already nearly 45 minutes behind schedule), I ended up simply ordering the tests rather than pursuing a discussion about whether the patient would even want to intervene in the case of a positive test.
This is not the type of care I strive to provide, but the care that I ended up providing as a result of both time constraints and perhaps a bit of what we are taught to prioritize in medical school.
Patient families
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While I am a health care provider, I am also a patient and a family member to many patients. For this portion, I am going to briefly reflect on my experiences as the family member of a patient.
In the past few years, my grandmother’s dementia has progressed significantly. In addition, due to some confusion regarding her medication regimen, she has also suffered significant vision loss. Our family, fortunately, has had the flexibility to have other family members care for my grandmother throughout the day. But this is uncommon and always emotionally, physically and mentally costly for the caretaker.
As many articles and blogs have illustrated, caring for an aging parent is a difficult task. The energy needed to watch and care for someone nearly 24/7 is immense and often simply too much to ask of an adult child who may already have chronic diseases of his or her own. This is a burden that is increasingly common and causing its own health concerns.
A geriatrics-driven health care system
These three mini-anecdotes are certainly not a comprehensive list of the issues impacting health care as our population ages. However, I hope they do illustrate that an aging population has far-reaching impacts on the provision of health care. While we do not all need to be geriatricians, any provider who cares for adults or any individual with interest in our health care system will need to understand how to care for the elderly.
It is a simple numbers game. There are going to be many more 65+ individuals in our health care system than in any other age group. As such, their needs are going to shape how we provide health care.
We have already seen how Medicare has shaped and driven changes in reimbursement structure and health care delivery. This is just the beginning.
Elaine Khoong is an internal medicine resident. This article
