Age-old Questions As Boomers Retire, Health Care Braces for New Challenges

The Baby Boom generation, the name given to the children born amid a post-World War II spike in the U.S. birth rate, now numbers about 78 million.

This year, the oldest of them will reach age 65, the number that, to many, signifies retirement and the beginning of the golden years. They’re entering those years at a time when the miracles of modern medicine are allowing people to live longer lives than at any time in history.

And that’s got many in health care extremely concerned.

“People are living longer, but they’re living longer with the burden of chronic disease,” said Dr. Maura Brennan, the program director for the Geriatrics Fellowship and director of the Geriatric Consultation Service at Baystate Medical Center. “We’re all looking for healthy aging, but sooner or later, illness and chronic conditions gang up on you. You only hope you can push that back as far as you can.”

The problem is, the pushing is going to be expensive. In its 2008 report “Retooling for an Aging America,” the Institute of Medicine (IOM) estimated that the number of Americans age 65 and over will nearly double between 2005 and 2030, due partly to the Baby Boomers crossing that threshold and life expectancy in the U.S. continuing to rise.

“While a large portion of this group will maintain health and independent functioning well past the age of 65,” the report states, “overall they will contribute to the challenges faced by a heavily burdened Medicare program. More than three-quarters of adults over age 65 suffer from at least one chronic medical condition that requires ongoing care and management. Older adults rely on health care services far more than other segments of the population.”

It’s not just an American phenomenon, said Jill Chaban, president of Sensible Senior Solutions, an elder-care consulting firm in Belchertown, who noted that the number of people 65 and older worldwide, estimated at 506 million as of midyear 2008, will rise to 1.3 billion by 2040.

“With this growth comes a number of challenges for both the seniors and their caregiving children,” she said. “Many of these seniors will need caregiving and support. The problem is, many of their children hold down a full-time job and have families themselves to care for.

“Families saddled with their own responsibilities,” Chaban added, “need to either take Mom or Dad in, find otherwise-appropriate personal care to visit at the home, or move their parent into an appropriate medical facility.”

The problem is, the health care system is already burdened by soaring costs — and no one knows how the implementation of national health-insurance reform will alter those numbers — and elder and end-of-life care tend to cost the most.

Adding millions of senior citizens to that equation over the next 20 years will likely require a significant shift in the way care is provided in the U.S., said Brennan. She cited the possible rise of accountable-care organizations — an efficiency-minded model that gets away from a ‘silo’ mentality of care and requires coordination among various providers — as one promising possibility.

But she and others say there needs to be a culture change, as well, and a rethinking of what care is necessary and appropriate toward the end of life. Because as the Boomers age — and, for that matter, retire from the health care workforce — issues of cost and access will only grow more severe.

Help Wanted

The Baby Boom years — roughly 1946 to 1964 — added what Brennan called a “staggering” number to the U.S. population.

“And I’m one of them,” the 60-year-old said. Millions of others went into health care around the time she did, and just as a tide of older patients requires more advanced care, a parallel wave of doctors, nurses, and other medical personnel from the Boomer generation will soon retire.

The aging of America, in short, “is happening precisely at a time when there is a shrinking of available providers,” Brennan said.

Nursing will be especially hard-hit; the long-publicized nursing shortage of the past decade has been somewhat ameliorated by a pickup in nursing school enrollments, but those numbers may be overwhelmed by the retirements of Boomer nurses, many of whom entered the field decades ago, when women were perceived to have fewer career choices than today, and nursing was among their top options. The average age of a nurse today hovers in the mid-40s.

Furthermore, at a time when the over-65 population will soon rise to 20{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the U.S. population, fewer than 1{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of current nurses specialize in geriatrics, and only around 7,000 doctors are specialists in that field, according to the NIH — and those numbers are also expected to decline.

An IOM committee charged with developing a strategy to deal with these challenges focused on three areas:

• Enhancing the geriatric competence of the health care workforce, perhaps by requiring providers to demonstrate competence in the specialized care of older adults as a criterion of licensure and certification. The committee also said patients and their at-home caregivers need to be better-integrated into the health care team and better-educated in self-management of their condition, to prevent costly readmissions.
• Increasing the recruitment and retention of geriatric specialists and caregivers, by improving the quality of these jobs, which are typically characterized by low pay, few opportunities for advancement, and high rates of on-the-job injuries. “It’s a grossly underpaid, underappreciated profession with an enormous amount of turnover,” Brennan said. The committee encouraged the development of loan-forgiveness programs and direct financial incentives to enter the field, and recommended that state Medicaid programs increase pay for direct care workers.
• Improving the way care is delivered, which includes better training, better pay commensurate with achieving new designations of geriatric competence, and federal financial incentives to develop technological advances that enhance the care of older patients.

‘A Good Death’

But boosting the number of providers isn’t enough, some medical professionals say; Americans need to have more-informed conversations about what care is most appropriate late in life.

Hospice care is a bundle of services available to people who choose to pursue end-of-life care rather than invasive, curative treatments, said Greg Keochakian, who runs Hospice of the Fisher Home in Amherst. The facility recently expanded from six to nine beds, and there’s a waiting list — reflecting a need that will only continue to grow as people live longer with chronic diseases, and the public becomes more aware of the benefits of hospice.

“What people are finding is that quality of life is being sacrificed for some short-term relief,” Keochakian said — but the goal of maximizing life at any cost has long been the dominant mindset in American medicine. “Hospice is a philosophy, and it’s difficult to switch philosophies midstream.”

Brennan said patients and doctors today share a culture where no procedure or treatment is too much if there’s the slightest chance of buying a little more life.

“And if there’s a reasonable likelihood that you’re going to get what you’re striving for, then God bless you. But by trying to extend life, you might waste some of the precious time you have, in and out of hospitals with procedures that are to your detriment,” she said.

That said, Brennan doesn’t blame anyone for clinging to a chance to get better, but she does wish people understood what hospice care really is so they could make an informed decision.

“I get really irritated when people talk about ‘comfort measures only.’ Only? There’s nothing only about it. You only get one chance to do it right, to help someone through that process of dying. It’s aggressive care, but it’s aggressively targeting a different goal. If you’re fighting for a goal you can’t achieve, you may lose what you’re able to achieve. It’s a difficult situation.”

Still, Keochakian said, “a lot of people are drawn to hospice by that philosophy. And I think the need for hospice has always been there. It’s most likely underutilized, so there will be a need to increase people’s awareness.”

Suzanne McElroy is well-aware of the benefits.

“Anyone who has experienced the death of a loved one and can describe it as a ‘good death,’ they understand,” said McElroy, who has seen two loved ones die at home, in bed, surrounded by family, and called it “a wonderful experience” — at least as positive an experience as death can be.

Where the Heart Is

Yet, McElroy doesn’t work in hospice; she owns the Springfield franchise of Home Instead, a national home-care chain that provides non-medical support services for adults, mainly seniors, who may need some help with the daily tasks of living but don’t need round-the-clock care. “Nobody wants to leave their homes,” she said.

Many home-care agencies provide nursing care in addition to services such as cooking, housecleaning, dressing, and transportation to appointments. In all cases, cost is a huge appeal, as home care typically costs a fraction of assisted living or nursing-home care. And, like hospice, the need for such services will only grow as the Boomer generation moves further into the golden years.

“I don’t think people are aware of how flexible home care can be,” McElroy said. “We are not usually the only answer; we’re part of a solution that usually includes family and friends — and, of course, that’s the backbone of caregiving in America. We form a relationship and become a partner in care.”

Chaban called home care a great option for many families, but they must determine how it will be paid for.

“Based on your parent’s financials, they may be eligible for payment of some of the care,” she said. “If not, there are many private-pay home-care companies in the area that offer assistance with bathing, grooming, dressing, and companionship.

“If your parent has medical needs,” Chaban added, “you will need to bring in a skilled-nursing company to check up on your family member. Skilled care is usually set up at the hospital upon a discharge and paid for by Medicare. After the Medicare paid time, this care will need to be paid for by the family. Typically, families can use monies from a long-term care policy or from savings to pay for this type of care.”

The home-care cost equation often balances out in the long term, McElroy said, as having someone around for part of the week, making sure their charge eats nutritious meals, drinks enough water, and takes medicine regularly can help prevent — or at least delay — a sudden decline in health that ends up with a hospital stay, rehab, and urgent questions about the possible need for a skilled-nursing facility.

It’s easy to assume, then, that the demand for home-care services — especially when weighed against the cost of assisted living or nursing-home care, and the desire of most people to remain at home — will only rise as the senior population increases. But that demand goes beyond the simple age factor, McElroy said.

“You have to look beyond the numbers, at the orientation of that demographic toward receiving services,” she told Healthcare News, noting that the generation preceding the Boomers, which came of age during the Depression, typically shared a reluctance to pay for services ranging from lawnmowing and housecleaning to elements of home care.

For Boomers, it’s different, she said. “If they have a problem, they Google it, and there will be an answer. That has really broken through a lot of the barriers we faced when dealing with the generation before them.”

Brennan agreed. “This cohort of older people is very different than the others that preceded it,” she said. “It is, in many ways, a more vocal, sophisticated group that will make more demands on the system than people who came through the Depression.”

It Still Takes a Village

Hospice care typically involves a team effort among any number of providers, often including a physician, nurse, social worker, dietitian, even a home-care aide, Brennan said. And even home care, with its reliance on care providers working alongside family members, replaces the it-takes-a-village mentality of past generations, when families lived closer together.

“We’re a very mobile society,” she told Healthcare News. “You don’t see a family of eight kids who all live in Springfield, taking turns taking care of Mom. More women are working, kids are moving away, people take second jobs, there’s more divorce. And there are fewer people around to help with care. It’s why many people end up in nursing homes.”

But the fiercely independent Baby Boom generation is characterized by people who have no desire to end up there, so they will continue to do their research and make demands of an increasingly strapped health care system.

“Everyone wants the longest life and the best-quality life,” Brennan said. “That’s what we all want. But doctors are frequently reluctant to bring up — or even think about themselves — the tradeoffs as the end of life approaches.”

About 78 million people are a little bit closer to having that conversation.