Meeting the Needs of Disabled Older Persons: Can the Fragments Be Pieced Together?

Abstract

ONE of the first things we learn in geriatrics is that, as people get older, their health needs extend beyond the purely medical. Actually, this is the case for other populations (e.g., very young children and all patients with devastating illnesses). The common issue is that these patients are unable to take their illnesses in stride and go on with the rest of their lives. Rather, health becomes the overriding force in their lives, and resources must be mounted to compensate for the deficits incurred by disease and debility. In geriatrics, the onset of functional impairment (particularly in activities of daily living) marks the transition of the role of health from bit player to lead actor. Certainly, older persons have larger disease burdens, but there is much more contributing to the impact of poor health including the loss of social support, financial limitations, and societal barriers such as the lack of geriatric-friendly housing and communities. When all of these are considered, it becomes obvious that care for the functionally impaired, community-dwelling elderly patient requires more than a physician or a health care system can provide. In the United States, we are celebrating the 40th anniversary of the Medicare program, a landmark piece of legislation enacted by the Johnson administration. As conceived, this program intended to relieve elderly Americans of the worry of becoming health care paupers once they retired and lost their commercial health insurance. The program has been enormously successful, though costly. Older persons have excellent access to health care and receive plenty of it. Yet, in its design and implementation, there have been inherent flaws in Medicare that fail to recognize the basic principle that medical care alone is insufficient. This oversight is understandable. The fee-for-service Medicare system was largely based on the Blue Cross and Blue Shield insurance plans, which were medically oriented and rewarded the volume of medical services provided, particularly procedures. In addition, life expectancy in the 1960s was substantially shorter (1) than today, and the numbers of older persons, those who were frail, was relatively small. Now, halfway through the first decade of the millennium, we are anticipating 75 million baby boomers who will begin to reach Medicare eligibility based on age in 2011. Moreover, the most rapidly growing age group in the United States is the 85 years and older population. With advancing age, functional impairment rises. For example, 20% of persons 65–74 years of age have difficulty with activities of daily living, whereas 53% of those 85 years and older have difficulty with these tasks (2). Providing assistance with these tasks largely remains outside the benefits package provided by Medicare. These demographic data underscore the pressing need to reconsider how health care is conceptualized for older persons. In the United States, several attempts have been initiated to blend medical and social services to meet the comprehensive medical and social needs of frail older persons. Among the most prominent has been the Program for Allinclusive Care of the Elderly (PACE) and the social health maintenance organizations (S/HMO). Both have had some successes (3,4) but they also have limitations (e.g., participants’ inability to retain their own physicians, high premiums for those who are not eligible for Medicaid, modest interest among insurers) and have not become widely available. In this issue of the Journal, Beland and colleagues report the results of a large, carefully conducted trial of an integrated (blending health and social services) health care delivery system (SIPA; French acronym for System of Integrated Care for Older Persons) launched in Canada (5). Some notable features of the SIPA system include assessment followed by evidence-based interdisciplinary protocols for the conditions that frail older people commonly experience (e.g., falls, heart failure, depression, dementia, medications). SIPA mobilized medical and social services, including case management, to keep patients out of the hospital. Another positive aspect of the program is that the patient’s family physician continues to provide the medical care. Moreover, the program provided financial incentives for physician participation ($400 annually, the equivalent of $33 [Canadian] per member per month) to compensate for time spent communicating with the multidisciplinary team. Although the results are not as positive as one might have hoped, the authors state that the findings of reducing more expensive care (acute care) while increasing less expensive care (e.g., home health) met the study’s hypotheses. Obviously, the model of care would have been more compelling if total costs were reduced. It is hard to persuade insurers and delivery systems to adopt change in the absence of a bottom line benefit on health or costs. Nevertheless, costs are a fickle outcome because of health care delivery idiosyncrasies and outliers, which can substantially influence