Baby Boomers May Overwhelm Entire U.S. Medical System


SAN FRANCISCO — The baby boomers might do more than bankrupt Medicare—they could break the entire medical system, members of a panel said at the annual meeting of the American College of Physicians.

With 76 million baby boomers starting to approach age 65, the elderly population will double by 2040, potentially bankrupting the Medicare trust fund by 2020 and Social Security by 2042.

But they may also overwhelm the health care system with chronic conditions. The medical system is set up to assume that patients with a chronic condition have only one, but most of the elderly have more than one chronic condition, said Robert A. Berenson, M.D., a senior fellow in health policy at the Urban Institute in Washington.

Of persons older than 65 years, 84% have at least one chronic condition, 62% have two or more, and 20% have four or more. People with chronic conditions see more physicians more often, which greatly increases the potential for inefficiency and confusion in their care, Dr. Berenson said.

The average person with no chronic conditions sees 1.3 physicians a year and has two medical visits. In contrast, the average person with five chronic conditions sees almost 14 physicians (including radiologists and anesthesiologists) per year and has a total of 37 visits, Dr. Berenson said.

A Harris survey asking persons with a chronic condition about their care in the preceding 12 months found 54% had been told they were at risk for a harmful drug interaction because of what they were taking, 54% had duplicate tests or procedures, 52% had received different diagnoses from different physicians, and 45% had received contradictory medical information.

Fundamental problems in the medical system must be addressed to manage the influx of baby boomers with multiple needs. These problems include the shortage of geriatricians; training oriented toward hospital care, rather than prevention and management of chronic conditions; and even the reliance on guidelines for care. Guidelines are generally written for one condition and tend to ignore comorbidities, Dr. Berenson said.

The growth of the elderly population is a problem compounded by the obesity epidemic and the sedentary lifestyle of many Americans, said David K. McCulloch, M.D., of GroupHealth Cooperative, Seattle.

To respond to this “triple whammy” crisis in health care, the medical system will have to reinvent itself to embrace more prevention and coordinated care, including adopting pay-for-performance strategies that offer providers incentives for keeping patients well, Dr. McCulloch said.

There is evidence that a chronic-illness model of care delivery that coordinates care and provides wellness services can reduce costs and hospitalizations and benefit patients. Many of the patients who can benefit from this approach are diabetic patients, he said.

At Dr. McCulloch's HMO, a 3-year pilot program for 18,000 diabetic patients decreased hospitalizations by 25% and overall costs by 11%, although pharmacy costs increased 16%. The program was credited with improving the patient group's average hemoglobin A1c levels significantly.

An unpublished Rand study found evidence that this type of program can be implemented in private physicians' practices, and that when one practice in an area adopts such an approach, other practices in the area begin to copy it, he said.

Dr. Berenson commented that the relative value, resource-based system of payment might have to be overhauled so that there is more incentive for good chronic-disease management.

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