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• W1521612726 abstract "The future apocalyptic vision is familiar to readers of the Journal—more old people, many of whom have chronic diseases, receive poor-quality care, and incur high healthcare costs. This vicious cycle is likely to increase over the next 30 years because of the entry of approximately 75 million baby boomers into the ranks of the elderly, many of whom will have high burdens of chronic diseases as obesity and sedentary lifestyles take their toll. As a result, we can expect spiraling healthcare expenses spurred by three forces: more older people, more services per older person, and more-expensive services. Meanwhile, the government is pursuing healthcare reform that covers the uninsured, reins in costs, and improves quality. This is a tall order for a healthcare nonsystem that is perfectly positioned to achieve mediocrity. Perhaps nowhere is this more evident than in the care of older people—an emblem of what is wrong with health care. In general, being old with chronic diseases in America means receiving a lot of health care, some appropriate and some inappropriate, with little coordination or consideration of the big picture. Rather, the lens has focused on the care of diseases and performance of procedures that permit a specialist to say, “stable from my perspective.” That approach fails when the single disease is not the root of the problem or is only one component of a tapestry of maladies. These older persons with multiple chronic illnesses are common; 43% of Medicare beneficiaries have three or more conditions,1 and 23% have more than five.2 Moreover, the percentage of persons with multiple chronic conditions rises with age,1 which is particularly ominous. During 2011 to 2030, the baby boomers will be younger and healthier. But in 2031, they will begin to turn 85, and we can expect the full brunt of the tidal wave of their health expenditures. In 2007, 10 foundations commissioned the Institute of Medicine (IOM) to conduct a study of workforce needs to provide care for older persons in the future. This report, issued in April 2008, was sweeping and broad in its recommendations for a better-prepared workforce including healthcare professionals who have not specialized in geriatrics, geriatrics specialists, direct care workers, and patients and informal caregivers (families and friends).3 The IOM report also emphasized that a better-trained workforce alone was insufficient to ensure better care for older persons: Simply expanding the capacity of the current system to meet the rising needs of older adults would not address the serious shortcomings in the care of this population. The committee created a vision for the future that rests on three key principles: •The health needs of the older population need to be addressed comprehensively. •Services need to be provided efficiently. •Older persons need to be active partners in their own care. The committee's vision represents a vast departure from the current system, and implementation will require a shift in the way that services are organized, financed, and delivered. In preparing its report, the IOM committee looked for better models of care that fit this vision and commissioned a study by Boult et al.4 to identify evidence-based (demonstrated effective in clinical trials and using other quasi-experimental designs) successful models of comprehensive care for older adults with chronic conditions. The principal findings of that commissioned study are published in this issue of the Journal, along with an article on improving chronic disease care by Robert Kane, a leading expert in long-term care.5 The articles are complementary and provide different perspectives on some of the same studies. Nevertheless, both articles lead to the same message: better ways to provide care for older persons with chronic diseases are available now. Perhaps the most striking finding of the article by Boult et al. is the sheer number of effective models of care identified—15 successful models based on 123 high-quality studies that reported positive outcomes! Unfortunately, most of these better approaches to care are currently unavailable to the vast majority of older persons who need them. Why? The answer is simple yet complex. Put simply, there are insufficient incentives to adopt new care models to replace the current dysfunctional healthcare delivery systems for older persons. Both articles mention financial and nonfinancial barriers to creating such incentives. In the American capitalistic society, the former are more important, because if the economic incentive is large enough, entrepreneurs will develop approaches to overcome the nonfinancial barriers. Nevertheless, early experience with patient-centered medical homes highlights some of these nonfinancial work flow and behavioral obstacles, as well as the inertia that perpetuates the status quo.6 To spread, innovations must be simple to understand and compatible with existing values, past experiences, and needs of potential adopters. They must also confer a relative advantage over current practices that can be easily seen and must be able to be tried before committing to adoption.7 Consider the example of the PowerPoint presentation, which eliminated 35-mm slides within a few years. Although it is unlikely that any healthcare delivery innovation would be so readily diffusible, these principles guide the decisions to adopt new practices. As I am writing this editorial, battles are being fought in Washington with the goal of fixing a flawed healthcare financing and delivery system. It is unlikely that this first attempt, if successful, will be comprehensive, and long-term care reform will almost certainly be absent from the legislation that may be signed in 2009. Thus, the innovative models identified in these articles will mostly continue to remain in mothballs. Perhaps it is time to think differently. Imagine a healthcare delivery system that cataloged its older patients' needs and then implemented models of care to address them. The menu of model options could come from those inventoried by Boult et al., as well as new models that have been tested after their review8, 9 or will be created in the future. Indeed, a specific recommendation of the IOM report was to promote the development of new models of care, particularly for prevention, long-term care, and palliative care. To implement these new models, the healthcare system would need to be released from the constraints of the fee-for-service reimbursement that currently covers the vast majority of Medicare beneficiaries. Instead, the healthcare delivery system would be paid a suitable amount per patient to provide all the appropriate care needed to meet the patient's goals and also be consistent with the goals of medicine. Hence, futile or ineffective care would not be provided. To be faithful to this vision, the healthcare system would need to have a moral commitment that runs throughout all levels of the organization—in essence a conscience. Safeguards would also need to be implemented to ensure that these systems are held accountable so that appropriate care is not withheld to maximize profits. Such an approach would have several advantages. First, it would allow the Centers for Medicare and Medicaid Services (CMS) to discard the current process of evaluating new innovations through the Medicare Demonstration Project mechanism, which is slow and fraught with design, fidelity, and evaluation limitations. Rather it would rely on the scientific community to develop and test new models of care and stimulate local innovation by healthcare systems. Second, this approach would obviate the need for CMS to rapidly price and promote successful new models. Instead it would place the onus of selecting and paying for models onto the healthcare delivery system, which has better insight into its patient population and local resources. This approach would also allow the healthcare system to set prices for providers. For example, if the system believed that geriatricians or primary care physicians were integral to the success of these models, it could pay them commensurate with their value. Similarly, it could promote the delegation of tasks to other healthcare providers, including the nonprofessional work force, who could perform them adequately and less expensively. The appeal of this approach is that it is available today and would not require major new legislation. There are examples of innovative healthcare systems in the United States today that receive high marks for quality and patient and provider satisfaction. They have implemented some of the models of care described by Boult et al. and Kane, as well as others that have not been published. Although the costs of care in the best of these innovative systems may be higher than we would like, these paradigm health systems may reflect how much it should cost to provide appropriate care and inform us about how best to do it. If this approach makes sense, then efforts should be taken to promote it within the healthcare community and to consumers, and in the process, we should come up with a new name for the kind of financing that fosters individualized care to meet older persons' individualized needs. The terms “managed care,”“health plan,” and “Medicare Advantage” send the wrong message. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contribution: David Reuben was the sole author of this editorial. Sponsor's Role: None." @default.
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• W1521612726 title "Better Ways to Care for Older Persons: Is Anybody Listening?" @default.
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