Healthcare Crisis 2030

APPROXIMATELY 75 MILLION Americans make up the demographic known as the baby boomer generation. The U.S. Census Bureau categorizes baby boomers as individuals born between 1946 and 1964, and if you do the math, it turns out that nearly three million of them will hit retirement age every year for the next two decades. By 2030, that means the number of Americans 65 and older will climb to more than 71 million, up from about 41 million in 2011, a 73 percent increase, according to U.S. Census Bureau estimates.¹ The question on many minds is: What influence will this aging demographic have on our nation’s public health, social services and healthcare systems? The answer: a staggering one. “This is the most powerful force operating in our health system right now, this generational change,” says Jeff Goldsmith, president of Health Futures Inc., Charlottesville, Va. “So far, the growth in the number of senior citizen boomers has been incremental, and its impact on healthcare has been overshadowed by federal reform and budget battles. People aren’t paying much attention.”¹

Addressing the Chronic Illness

Crisis While today’s seniors are living longer than previous generations, they are not necessarily aging well. In fact, one of the biggest healthcare hurdles facing hospitals and healthcare systems during the next several decades will be the management of chronic diseases within this rapidly growing population. A joint report from First Consulting Group and the American Hospital Association, titled “When I’m 64 … How Boomers Will Change Health Care,”² noted the following estimates.

By 2030:

• 14 million boomers will have diabetes;
• 26 million will have arthritis;
• More than 21 million will be considered obese;
• Knee replacement surgeries will increase 800 percent; and
• Hospital admissions among boomers will increase more than 100 percent, totaling half of all admissions in America.

Experts agree that the chronic illness crisis among aging Americans presents one of the biggest challenges to an already taxed healthcare system. According to Baby Boomer magazine, two-thirds of this aging population are expected to have as many as five chronic diseases by age 65.³ Clearly, a multipronged approach will be needed to prepare physicians for this onslaught of patients and the resulting avalanche of prescription medications and treatment plans.

To address the rising concern, the American Medical Association has established a policy requiring all physicians with older patients to be competent in geriatrics. This policy applies to physicians at all levels, including undergraduates, residents and practicing physicians. In addition, the American Association of Medical Colleges has developed programs for medical students covering 26 geriatric competencies, including being able to explain the impact of age-related changes on drug selection and dosage; diagnosing dementia; and talking with patients and families about palliative care. 3 Similar competencies in geriatrics are in development for residents in the fields of surgery, family medicine, internal medicine and emergency medicine, and for other specialists involved in treating older patients.

When patients present with multiple chronic illnesses, it puts a strain not only on healthcare providers, but on Medicare. As the founder and president of the Alliance for Aging Research, Daniel Perry, explained, “The reality is most elderly people do not have one disease on their death certificates.” He notes that elderly patients often receive care from more than one specialist, as well as a primary care provider, but the current healthcare system in the U.S. does not support coordination and collaboration between providers in different fields. “We don’t have a healthcare system that is well-designed to diagnose, assess, prevent, postpone and treat the multiple chronic conditions that accompany the aging process,” Perry says.²

Preparing for the Dementia Dilemma

A 2015 study conducted by the Lewin Group in Falls Church, Va., for the Alzheimer’s Association offered dire predictions for onset of Alzheimer’s disease (AD) in baby boomers. According to the study, more than 28 million future seniors could be diagnosed with AD by 2050, accounting for nearly 25 percent of Medicare spending by 2040. The study also predicts that the prevalence of AD in baby boomers will rise from 1.2 percent in 2020, when most will be in their 60s and 70s, to an astonishing 50.1 percent in 2050, when these individuals reach their mid-80s and older. By 2040, more than twice as many baby boomers will have AD (10.3 million) than the equivalent age group had in 2015 (4.7 million).⁴

“The risk of Alzheimer’s increases with age, and as baby boomers get older ― because of the size of the generation ― the number of people developing the disease will rise to levels far beyond anything we’ve seen. The size of this generation is the major factor here,” says Christine Bredfeldt, PhD, from the Lewin Group. “The study is important because it is based on an updated model that charts the trajectory and economic impact of Alzheimer’s based on the rate of new diagnoses, the number of people who will be living with the disease and the cost of medical and long-term care between now and 2050.”⁴

The findings of the study speak to the urgency of addressing future Medicare costs for this at-risk population. Predictions estimatethe cost of caring for morethan 10 million AD patients could consume nearly 25 percent of Medicare spending. That number represents the longer-expected lifespan of the boomer generation coupled with the progressive nature of the disease, resulting in the widespread need for long-term or nursing home care.

A new study launched in September titled the “Alzheimer’s Prevention Initiative Generation Study” is unique because it specifically targets baby boomers as study enrollees, focusing on individuals who are 60 years to 75 years of age and currently showing no signs of cognitive impairment. Enrollees are also those who inherited two copies of the e4 type of the apolipoprotein E (APOE) gene, the major genetic risk factor for developing AD at older ages.⁵ The goal of the study is to test whether either or both of two investigational compounds — an active immunotherapy and an oral medication — compared to placebo might prevent or delay the emergence of AD symptoms in people who are at particularly high risk for developing the disease at older ages because of their genetic profile. “Even if this research only results in our ability to delay the onset of Alzheimer’s disease by five years, theimpact could beenormous,” says Pierre Tariot, MD, director of the Banner Alzheimer’s Institute (BAI) and coprincipal investigator for the study. “Some estimates indicate that even a short delay could reduce the number of Alzheimer’s cases by 50 percent. That’s quite a legacy for baby boomers to leave future generations.”⁶

The five-year study is sponsored by Novartis, a Swiss pharmaceutical company, and Amgen, a biotechnology company based in Thousand Oaks, Calif., in collaboration with BAI, and with funding from the National Institute on Aging, as well as the Alzheimer’s Association, Fidelity Biosciences Research Initiative, GHR Foundation and Banner Alzheimer’s Foundation.

Training the Next Generation of Geriatric Physicians

Like older adolescents aging out of pediatric care, aging baby boomers will also need to transition from their current general practitioners to physicians with expertise in geriatrics. According to some estimates, there are currently only 7,000 certified geriatricians in the U.S. — far too few for the coming wave of senior citizens. To address this, four academic medical centers that are leaders in geriatric care — the Icahn School of Medicine at Mount Sinai, the Johns Hopkins University School of Medicine, Duke University School of Medicine and the University of California, Los Angeles (UCLA) School of Medicine — formed a consortium to provide geriatric training to physicians who teach in medical schools and residency programs.⁷

Known as the Faculty Development to Advance Geriatric Education, or FD-AGE, the program doesn’t aim to create new geriatricians; rather, its goal is to teach physician-educators from all specialties how to address the complex issues involved in the care of older adults. The hope is that they will go back to their home institutions and pass on what they have learned. “The FD-AGE program is a recognition that most older people won’t be cared for by a geriatrician,” says Rosanne Leipzig, professor of geriatrics and palliative medicine at the Icahn School of Medicine and a consortium leader.⁷

Ethan Cumbler, MD, an associate professor of medicine at the University of Colorado who specializes in the practice of hospital medicine, set up the only hospital unit specializing in the care of the elderly in Colorado after taking part in the FD-AGE program at UCLA in 2007 and 2008. When teaching other physicians, Dr. Cumbler stresses that treating elderly patients requires a holistic approach that takes into consideration all of their physiological, psychological, economic and social issues.⁷

In addition to training the next generation of providers, models of care will need to evolve to address a rapidly aging population. The white paper “Retooling for an Aging America: Building the Healthcare Workforce”8 addresses this need, explaining that the current healthcare system often fails to provide high-quality care to older adults, in part because services are often delivered by many different providers with limited or no collaboration. For example, in the current “pay-for-service” healthcare environment, a patient managing several chronic diseases is likely seeing an equal number of specialists requiring multiple office visits.

“Chronically ill Medicare beneficiaries often see multiple physicians — all working within their own silo — with no one physician responsible for all care. In our fractured delivery system, no one physician takes responsibility for guidelines-based care, and health information is most often not shared among these silos,” state Michael O. Fleming, MD, and Tara Trahan Haney, MPA, in a PubMed report.⁹ According to the authors, in the absence of a care coordinator, there is often a breakdown in communication between the patient and the physician team: “In many instances, a patient is admitted to the hospital, but the primary care physician never knows about the event or any medication changes that resulted, thereby increasing the chances of a readmission.”

With the rise of chronic illness within baby boomer patients, hospital admission and readmission represent a significant expense for Medicare. According to research published in the New England Journal of Medicine, one in five Medicare patients ended up back in the hospital less than 30 days after discharge in 2003 and 2004.¹⁰ And, while many hospital readmissions are unavoidable, experts believe that hospitals can engage in several activities to lower their rate of readmissions and related costs. In 2012, the Centers for Medicare and Medicaid Services (CMS) launched the Medicare Hospital Readmission Reduction Program as part of the Affordable Care Act. The program fines certain hospitals for excessive rates of readmissions for Medicare patients with specified conditions. Early evidence suggests that the program is showing signs of success.¹⁰

Reinventing Care Models for an Aging Population

As we look to the future, the healthcare community has a unique opportunity to adopt a new approach to healthcare delivery, one that promotes patient-centered care coordination, from the first diagnosis of a chronic illness throughout the continuum of care. While many innovative models of care show promise, implementation to date has been minimal. What is clear is there is not a one-size-fits-all approach that can meet the changing and diverse needs of an aging patient population.

Experts suggest there will need to be a paradigm shift when it comes to identifying the healthcare team as a whole, which will likely expand to include everyone involved in a patient’s care, from healthcare professionals, direct care workers and nonprofessional caregivers (including family and friends) to the patients themselves. Giving each of these stakeholders access to the data, knowledge and tools needed to provide high-quality care can be accomplished using a variety of assistive technologies, remote monitoring systems and mobile health, potentially reducing the need for in-office care. Health information technologies and remote monitoring systems, for example, can allow for more healthcare to take place in the home care setting to improve communication among all caregivers and enable providers to make more efficient use of their time.

An article in Today’s Geriatric Medicine titled “Remote Monitoring in Geriatric Care” notes that the success of passive monitoring stems from its ability to collect data continuously and alert caregivers in real time of any changes or fluctuations. Although proven to be a valuable tool, remote monitoring use remains inconsistent throughout the industry as the regulatory environment becomes increasingly complex. In 2014, CMS drafted a provision to cover remote monitoring for managing chronic care, although reimbursements are limited to certain providers, conditions and types of remote patient monitoring. However, as adoption increases and providers demonstrate its value, CMS could begin to incentivize monitoring as a pay-for-performance measure — a move that could be mutually beneficial to both providers and the aging baby boomers whose long-term quality of life may very well hang in the balance.¹¹

Beyond technology, new comprehensive care facilities may also address the needs of aging adults, including specialized acute care for the elderly units in hospitals and resident facilities that offer a spectrum of medical assistance, from assisted living through advanced dementia care.

For more than seven decades, the baby boomer generation has influenced everything from marketing and economic trends to the country’s political climate. As they step into their golden years, this highly opinionated and vocal demographic will likely be the key driver when it comes to future healthcare trends as well. “A lot of people strongly believe that baby boomers in particular are going to receive a lot of their care in the future over the Internet, over the phone,” says Richard Birkel, senior vice president for the Center for Healthy Aging and director, self-care management alliance at the National Council on Aging, a nonprofit service and advocacy group. “Healthcare is going to have a significant e-health component. It does already, but nothing like we’re going to see in the next five to 10 years, and I think baby boomers are going to be leaders in that area.”¹