Seniors - Part 1 of three articles on the impact of Seniors on Healthcare
Seniors – Avoiding the Healthcare Crunch
“The only thing special about the baby boomers is that there are so many of them."
The Seniors are coming!
We are just coming to understand how improvements in parenting during the first six years of life can have substantial long-term positive affects on the emotional, educational, economic and health outcomes of our population.
This paper will suggest that we can use the same kind of analysis and approach to mitigate the potential risks of our health system and to our economy by the impending collision between our already overstretched healthcare system and the massive increase in potential load caused by the Baby Boomers shifting into the realm of seniors.
In the past, seniors made up only a small percentage of society. It is the “Boomer” aspect that will change everything. At every point in the life cycle, the sheer weight and scale of this group has shaken the institution of the day. This is the group that forced the building of all those schools, that forced the expansion of universities, that pushed up the price of housing, that built the suburbs. This is the group that will hit the healthcare system. The advance guard is here already. As a group its average age is already 50 today. As it hits 60 in 2010, the full impact will start to be felt as about 10 million Canadian enter the early stages of old age.
“Cost drivers such as Canada's growing and ageing population and inflation are projected to increase provincial/territorial health expenditures from $56 billion to $85 billion in 10 years. This cost increase is likely an underestimate, as it does not take into account cost accelerators such as emerging and new technologies, the increased incidence of chronic and new diseases, and the cost of renewal. This could bring total provincial/territorial health spending to over $100 billion within the next decade.”
We all “Know this”. But do we? We have an intellectual understanding. But we have not felt or experienced the impact yet so it may not feel “real”. So let’s dimension the potential problem so that we can feel its full scale and weight. We will then look at the most important factors and their interrelationships so that we can see the underlying system. Finally, we will examine what actions we can take to avoid the crunch.
Solving the Paradox
Using our current set of assumptions and our current operational doctrine, costs to the health system increase as we age and as we introduce new an expensive new sets of diagnostic and treatment technology.
This chart shows the playing out of the assumption that our health at all stages and especially in old age is dependent on an exponential increase in direct medical intervention of an ever more sophisticated and expensive nature. No efficiency, or traditional cost cutting, approach will alter this trajectory of potential costs. Only finding another way will enable us to avoid the crunch.
In this paper we will find this other way. We will answer the paradoxical question of how we can significantly reduce the demand on, and hence costs to, society and the healthcare system while improving the patient experience and population health outcomes. Impossible? Not if we look outside of the box. In so doing, we will challenge a core assumption along the way. Principally that:
Access to the medical profession, to hospitals and to medication is the most important factor in maintaining the health of seniors
The core assumption underlying our approach, once we have included genetic predispositions, is that human health is significantly influenced by mindset, how we see and value our selves and our immediate and societal environment. People with a sense of purpose, who feel that they are valued, who have high autonomy and who have a strong support system of relationships tend not to be ill.
The main part of this paper will be concerned with reducing the demand on both the formal health care system and on long term care institutions. Our approach will be to set up the conditions that will support seniors being well and thus reducing their need to access the acute care system and reduce the need to live in institutions. We will also explore a practical alternative to the modern highly medicalzed view of death: the most expensive aspect of the relationship between the system and the individual.
We will not avoid consideration of the existing formal healthcare system We will offer two substantive new ways of delivering healthcare to seniors that will dramatically reduce costs, improve service and reduce the load on the medical profession.
We will also look at the growing shortage of medical professionals and offer some novel suggestions as to how best to improve this situation.
But first, let’s look at the scale of the problem that confronts us. How much risk are we exposed to? Can we simply attempt to do what we do now but more efficiently? Or are we going to be compelled to think outside of the box?
What is the dimension of the risk?
Let’s begin by looking at the conventional intersection between the healthcare system and the elderly
An important assumption is that new drugs and new surgical and medical treatments will create demand of an increasingly technical perspective.
Direct Costs – At the moment, Health Canada’s view of the future is a reasonable one. As we get older we cost more. A lot more. In 1994, health care spending in Atlantic Canada for those over 65 was $6,126 per person. For those between 45 and 64, it was $1,439 per person. When the two groups are combined it adds up to 75% of health care spending. This increase is driven by higher drug use, more technical intervention, more frequent and longer stay visits to hospitals and more institutional care for those who cannot care for themselves. On Prince Edward Island in 1994 this age group drove $98.00 million of the direct costs to the Health care system or 47% of the budget. By 2010 the sample size that forms this age group will have expanded dramatically.
So, if we change nothing in how we approach seniors and if they continue to behave as their parents, the fears of Health Canada will be realized.
Drugs – A powerful driver in this trajectory of cost increase is our faith in prescription drugs. The Provincial drug budget is increasing at a rate of 8% compounded a year. The fastest growing sector of cost growth in the healthcare system is drug use. The heaviest users of drugs are seniors. In the US, the drug use numbers are staggering
As an individual, it may seem that access to cheap drugs is a boon, a right and life saving.
Are we seeing a commensurate improvement in mortality rates as a result of this dramatic investment in medication? If we are not, then why do we support this?
This raises a very difficult assumption that is deeply ingrained in our culture. We have become so impressed by science, after all it has defeated most of the infectious diseases that killed our grandparents, that we appear to believe that we can conquer death itself.
This important trend tells us that we believe that the main driver for health is access to medication. For seniors and the medical profession this is currently a cornerstone belief..
This linkage with drugs also forces the use of hospitals and works against any home care alternative in Canada. Drugs in hospital are “free” while drugs at home are a cost to the patient. This strange design requires the terminally ill and those in pain to insist on being admitted. How then can we alter this view? It is helpful in discussing this delicate subject to look at the facts of what we die from.
“Curing Death” – About 1,200 people die each year on Prince Edward Island. In total this is not a large number. But because we are a small community, each death affects us in a way that does not occur in Ontario where no one knows their neighbours and 80,000 die a year. We “Run for the Cure”, we donate to the “Heart and Stroke”. Is it because we think that one day we hope that we will cure death itself?
This snapshot of causes of death in 1997 shows that Cancer and CHD are the main causes of death today with nearly 60% of deaths. A problematic aspect of our belief system both as individuals and as members of the medical profession is that somehow most of the causes of death on this list are somehow “curable”. If in the end, all the diseases on this list are “curable” then what will we die from?
Do we have a choice of what we will die from or how and when we will die?
It is interesting to see that only 3.7% of deaths occur from the “Old Man’s Friend”, pneumonia. 50 years ago, we would have found pneumonia near the top of the list. There is an important story behind this statistic. What happens is that a cancer, or a seriously ill CHD, patient will contract pneumonia while bedridden in hospital and be cured of pneumonia only to die later painfully of their cancer or of the heart attack that they fear the most. We “cure” the easy death only to condemn the patient to the hard death.
Recently, results of an eight-year clinical study of dying in America, (funded by the Robert Wood Johnson Foundation) revealed that half of the 9,105 terminally-ill patients studied spent at least eight days comatose, in intensive care, or in pain just before they died. Little relationship was found between what patients wanted and what, in fact, physicians did. Living wills made little difference.
Are doctors the experts on aging and death? “Given the medicalization of old age, the dramatic increases in their numbers, and the fact that those 65 and older account for 44% of all days spent in the hospital and one-third of the nation's health care expenditures, it is ironic how, as of 1993, only eight of the nation's 126 medical schools required separate courses in geriatric medicine and there were only about 4,000 board-certified geriatricians in the United States.”
The family and the medical profession all have a deep need to do something. When the only choice is intervention, that is the choice that we all will take. “With medicine controlling the final rite of passage, death is being stripped of many of its traditional moral connotations; the dying are stripped of their identities and their pasts. With continuing advances in medical technology, symptoms as opposed to whole selves increasingly become the unit of treatment. Death is increasingly perceived to be a "technological phenomenon" that occurs when medical staff decide that nothing more can be done. As a result, death is decreasingly likely to convey any of the meaning that brought solace to generations past, and the deceased are remembered not for who they were but rather for what killed them.”
When we look later in the paper to solutions, we will pay particular attention to the question of how can we change this deep set and habitual response to serious illness?
Long Term Care and the death of our parents will raise the issues of aging for the Boomers – Witnessing our own end through our parents’ last years will be the experience that will open up the boomers to seek changes for themselves.
Just as the boomers rejected their parents highly managed and medicalized view of birth, many will reject their parents highly institutionalized and medicalized view of death.
Aging and death have been off the boomers’ radar screen. They have been largely been concerned with the issues of raising their children, school and higher education, home ownership and their own needs to find and hold work. Most of the boomers’ children are now between 15 and 30 and will be leaving home soon and setting up their own lives. Most home-owning Boomers will have paid off their mortgage and most will retire in the next 10 years. Just as they become free at last, they will face the final years of their parents.
The boomers’ parents are now between the ages of 65 and 85. In 10 years most of them will move into their 80’s and die. Coping with the aging and death of the boomers parents will become a very important social and political issue in the first decade of the 21st century.
The first shift in the experience of the Boomers will be when they have to answer the question of what to do when their parents cannot look after themselves anymore. This is happening now.
But if we look at those over 85, the picture is quite different. 1/3 of people over 85 are currently in institutions.
Most are single women whose spouses have died. They will have lost their most important support, their husband. 
This demographic group will expand nationally in the next 20 years by 57%. . By 2010, 100,000 seniors over 80 will be living in Atlantic Canada. Most will be women. In Atlantic Canada, out-migration of the young and the rural nature of our society will make the question of what to do with Mum even more pressing and problematic.
Many more of the children of the elderly will not live on Prince Edward Island or in the same community as their parents
Their children will be between 50 and 60 years old and be defined as seniors themselves.
Already in 1991 1/3 of senior women said that their closest family member lived in another town. 50% said that they had no close family member
50% will come from Rural communities of less than 1,000 people, where there will be no alternative but institutionalization in a major centre.
Because Boomers will have to become so involved with their own parents,. The issues will not be academic or abstract.
All of us will have to help make tough decisions about where our parents will live and, in the end, what shall we do with the elderly surviving spouse. All of us will confront the fact that when our parents are very ill that there is so little choice open to us. Most of us will witness our parents enduring a hospital death with all the attendant de-humanization that attends this option.
This experience will open up large numbers of Boomers to seek changes in how they will age and in the end, die.
The new mindset of Boomers that will help us change the system - As Boomers enter old age themselves they will have just witnessed their parents aging and death. They will face twice the longevity of the great grandparents and will redefine aging. They will have strong views. They will both demand change and be open to change if it is offered to them.
They will become a major community-building resource. They do not see themselves as “Old” and they will seek a more active life than their parents. Many will retire at 55 and will see “retirement” as merely the beginning of an entirely new way of working. Meaningful work will be an essential factor in keeping the middle-aged and seniors healthy. At the moment, men are at risk of losing their key role and self identity as those over 55 are shut out of the labour force. “What do you do?” is still the first question that we are asked. Not having a role is a serious impediment to our health, especially for men who so closely link themselves with paid work.
They will work to live and not live to work.
They represent an important community restoring force and a new kind of labour pool. Much of what they want to do is to give back to their community. Their need to work is less driven by a need for income and more driven by a need for achieving purpose, role, recognition and fellowship. People who have these things tend not to be ill.
Role is emerging as an important health factor. A new body of research is being developed to examine the linkages between the elderly having control of key roles and their health and mortality. “… identity theory specifies that they will be able to find a deep sense of meaning and purpose in life. This is important because maintaining a sense of personal meaning may have health protective effects.” As such, encouraging seniors to work will have a positive health outcome. We will examine some options to meet this role need later.
They can regenerate our cities. They will rattle around in the empty and silent suburban family home for just so long. Housing needs will reverse. Just as the Boomers, looking for a place to raise their children, moved out of the city centres for the suburbs, so the middle-aged and seniors will look again at the city centre as an ideal place to live. Mowing, driving and maintaining a large an empty house in the suburbs does not fit the lifestyle or needs of the post child-raising family. There is a tremendous opportunity here to plan to regenerate the downtown core with all the attendant social and economic benefits that a thriving, compact city centre has. A compact city centre drives a strong sense of community and relatedness which reduces isolation, a key factor in improving health outcomes. A compact city centre brings with it an increase in local infrastructure of all types, shops, doctors offices etc. which reduce an important challenge for seniors who wish to be independent, transport. A compact city centre is a major contributor to crime reduction and of course increases the tax base, thus setting in motion a virtuous circle of increasing resources. Signs of this trend are evident already, especially in larger cities such as Toronto. Deliberately designing incentives to build on this latent demand for urban housing will have powerful health outcomes. We will look at some supporting options for housing later.
The cost of a seniors residence on PEI is roughly $36,000 a year for the residential portion. This is a significant strain on either a family or the state. 
5,000 widows in nursing homes at this rate would cost PEI $180,000,000 a year or 2/3 of the current entire budget for Health and Social services.
Today we all worry about how we will pay for our children’s university. University fees and living costs will pale as a large number of Islanders face the long term costs of looking after their parents.
Currently we have few choices other than institutions.
How do we enable couples to remain together as they get older and how do we help single women create a sense of community? We will look at this later.
Most importantly, Boomers will increasingly reject the “medical death” and will seek to find alternatives that enable them to choose how and when they will die and of what.
In the US 28% of all Medicare is spent in the last year of life and 50% of these costs are spent in the last 2 months. If we translate these proportions to PEI, it might mean that of the $160 million we spend on delivery, $47 million is spent on the final year of life for the 1,200 Islanders who die each year, ($39,000 per person) and $23 million is spent in a vain attempt to cure death in the last 2 months of life! If we look at Ontario with 70,000 deaths a year and use $39,000 as the individual cost, then the last year of life cost number is just under $3 billion. At the moment the system is set up to guarantee this type of cost.
Most of us will admit our dying parent into hospital where they will be aggressively treated until they die. We don’t really want this: “There is a great divide separating the kind of care Americans say they want at the end of life and what our culture currently provides. Surveys show that we want to die at home, free of pain, surrounded by the people we love. But the vast majority of us die in the hospital, alone, and experiencing unnecessary discomfort.”
Currently we have little choice when confronted with imminent death. Your father has been ill and disabled now for 6 years. He is completely dependent on your mother, who has not had a day to herself all this time. He has just had his third heart attack and he is rushed into the hospital where the ER team resuscitate him. They too have no choice. They cannot sit by and watch a patient die. It is their job to bring him back if they can. After weeks in intensive care, he is well enough to leave hospital but not well enough to go home. So he is shipped off to a nursing home where he dies alone, of another heart attack, in the middle of the night on a weekend. You, the daughter, live and work in Toronto. You have been visiting your father in hospital on the Island constantly. But work keeps pulling you back. You were at home in Toronto and missed his death. You are filled with guilt and remorse for not being there. Your mother, exhausted and alone, was taking a short break from her daily vigil at the nursing home and is also filled with guilt that somehow she should have been there and done more.
If you experience this kind of death, as many of us do in some form, you will seek to find another way for yourself.
Death is where most of the costs lie. The costs are financial for both the Healthcare system and for the families. The costs are psychic for the surviving family.
Creating more choice about how we die and more choice as to how we manage the process and all the attached work and complexity is the single most productive place for us to work to avoid the “crunch”. We will look carefully at this area later.
 1999 Health Canada report by Susan Lilley and Joan Campbell – “Shifting Sands – The Changing Shape of Atlantic Canada. Economic and demographic trends and their impact on Seniors.”
·  In the US, the 50-plus consume 74% of all prescription drugs, a $100 billion market
· The 55-plus spend $467 per capita on prescription drugs, more than double the average
· They account for 51% of all over-the-counter drug purchases
Source – Ken Dychtwald “Age Wave”
 SOCIAL GERONTOLOGY & THE AGING REVOLUTION: The best Website on the topic (http://www.trinity.edu/~mkearl/geron.html#in)
 This slide is US data from an excellent source that explores a wide range of issues for seniors. Federal Interagency Forum on Aging Related Statistics.
For more information visit the Forum’s web site at www.agingstats.gov or call 301-458-4460
 Statistics Canada
 1999 Health Canada report by Susan Lilley and Joan Campbell – “Shifting Sands – The Changing Shape of Atlantic Canada. Economic and demographic trends and their impact on Seniors.”
 Since seniors are at greater risk of needing health and long-term care services than other population groups, spending on seniors for these purposes as a percentage of Gross Domestic Product is likely to grow. For example, Japan's health care costs for seniors aged 70 and above have grown tenfold over the past 20 years and have reached around 30 percent of total national health care expenditures. With the rapid aging of the population and changing family structure, Japanese caregiving responsibilities are increasingly shifting from families to the government and social service agencies.
 $39 million Medical Services; $21 million Acute & Continuing Care; $88 million In province Acute Care Hospitals; $13 million Pharmacy ( Provincial 2000/01 Estimate)
 Bill Moyers