Demographic Realities and Our Health Care System
We can be sure of few things in life, but the fact that we all age is one of those. The many changes in our health care system over the past fifty years also have demonstrated that we can be certain of few things there as well. But, the inevitable growth of our senior population and the significant demands this will put upon that system are among those few. How will we manage this expansion in a system redesigned away from a focus on care of patients to corporate earnings growth as its measure of success?
In the past, physicians managed the health care system and their focus was on patient care; financial strain on the system was considered secondary to patient well being. This focus resulted in a slow but steady increase in the cost of health care from about 1970 to the nineties. The increase was engendered largely by the introduction and acceptance of superb technology that brought about increasingly efficient and accurate diagnosis and treatment. This was to the benefit of patients but also increased the cost of care substantially. This cost increase brought about measures to curtail it. Among these were the development of Relative Value Units for the calculation of specific charges for specific therapeutic activities and diagnosis-related groups that provided a fixed payment for specific diagnoses and treatments. When these failed to halt the inexorable cost increases, corporate business was invited in to insert “good business practices” into health care. This was when medicine lost its soul and patients lost their place as the focus of medical care. Corporate earnings became more important. None of the changes introduced by big business made any difference. The cost of health care as a percent of the GDP continued to climb. Business grew its middle management and executive ranks and those costs were added to the continuing costs of technology. The health care bill escalated as for-profit health care eroded the physician-patient relationship and made health care more of a technical exercise. This is where we are today.
The aging population has and will continue to be the cause of considerable strain on the health care system as their demands and needs come into direct conflict with corporate profit expectations. Seniors have many medical issues, some caused by the insecurity and worry that go with ageing and others due to chronic diseases that grow more serious. Diabetes, cardiovascular disease, chronic lung disease are three common medical problems that plague seniors and require increasing amounts of care. Acute problems associated with the above or trauma from falls add to the medical load. Seniors will stress the healthcare system until the demographic bulge of the baby boomers works its way through life.
How will these be managed? The cost to the patient for healthcare will go up, as insurance companies and health care institutions try to maintain their profit margins, but that will not address the problem of caseload. Caseload will be managed at first by shifting the screening visits, which still will be called primary care, from physicians to physician assistants and nurse practitioners. Physicians will serve as backup. Many problems will be managed well; many others, related to chronic disease complications, may not. There will be an inevitable decline in the quality and availability of care for persons who need it most. Managing this burden will require more physician extenders, which in turn will require more primary care physicians devoted to geriatrics. It takes time to educate and train these people. There is a movement to decrease the time in medical school and post-graduate training for persons who will devote themselves to primary care. This will create two classes of physicians, which I believe is not a good thing since it dilutes the quality of the degree, but it may be necessary. We will need more of these people than our present medical education system produces. We also will need more in the way of facilities and infrastructure specifically for geriatric patients. Simply sending the case overload to the Emergency Room does not solve the problem; its increases the expense. Emergency care is far more expensive than a clinic visit.
Organizations that support seniors must advocate for these changes now, so that our health care system will be prepared for the change that is coming. People who have paid the most into the health care system should receive the best care and not be set aside because our system has not prepared itself.